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CIGNA DENTAL PPO
Dental Office Reference Guide
Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company or affiliates
552684 r 0320
1PPO | Dental Office Reference Guide
Table of contents
Introduction 3
Benefits for network dentists 4
Source of patients 4
Services to promote your practice 4
Cigna Dental Health Provider Solutions 5
Online credentialing tool 5
Cigna for Health Care Professionals website (CignaforHCPcom) 5
Electronic claims submission 5
Electronic funds transfer and electronic remittance advice 7
Interactive voice response (IVR) ndash Speech recognition technology 9
Cultural competency training and resources 9
Definitions 10
Plan descriptions 12
PPO dental plans 12
Exclusive provider organization (EPO) dental plans 12
Optional programs 12
Cigna Network Rewards Program 13
Administrative policies and guidelines 14
Appointment wait time 14
Billing guidelines 15
Benefits and eligibility verification process 15
Compensation 15
Treatment plans policy 16
Non-covered services 16
Covered Services not paid by Cigna 16
Covered Services not listed in your Fee Schedule 17
Services not covered listed in Memberrsquos Certificate booklet 17
State-specific legislation for non-covered services 17
Alternate benefit provision 17
National provider identifier 18
Use of Social Security numbers 18
Claims submission 19
Who should submit claims 19
When to submit claims 19
How to submit a claim 19
Electronic claims (837) and attachments 19
Electronic remittance advice (835) 20
Real-time request transactions (270 276 278) 20
ADA codes and electronic transactions 20
Coordination of Benefits 21
Orthodontic claims 21
Invisalignreg cosmetic appliances 21
Orthodontics in progress Change in Fee Schedule or dental health professional status 21
Surgical cases 21
Cigna debit card 21
Cigna claim attachment guidelines 22
Communications 23
Directory Accuracy Legislation 23
Dental participation guidelines 24
Conditions for participation 24
The dental facility 24
General office appearance and access 24
Sterilization and infection control 24
Radiology safety 25
Environmental safety 25
Medical emergency preparedness 26
Patient recordkeeping 26
Additional Guidelines 28
Provider data changes 28
Closing the office to new members 28
Terminating your participation 28
Continued on the next page
2PPO | Dental Office Reference Guide
Language Assistance Services 29
Member complaints and surveys 31
Provider appeals and complaints 32
State-specific guidelines 33
Use of name 34
Quality and utilization management 35
Provider credentialing requirements 35
Recredentialing 35
Onsite reviews 36
Utilization management 36
Cigna Dental Oral Health Integration Program 38
Patients eligible to participate in the program 38
Provider reimbursement 39
Member reimbursement 39
Clinical policies and guidelines 40
Clinical coverage determination guidelines 40
Comprehensive periodontal evaluations 40
Emergency care 40
Infection control 40
Periodontal regenerative procedures 41
Specialty recommendations 41
Radiographs 42
Use of equipment 45
Contact information 46
Table of contents (continued)
3PPO | Dental Office Reference Guide
Welcome to the Cigna Dental PPO Network
We value your participation as a network dentist and
strive to partner with you to support your success
Our philosophy stresses the importance of preventive
dentistry and early intervention in the disease process
We believe this approach benefits both the patient
and the dentist We know that a successful managed
dental care program is built on long-term relationships
mutual rewards and common goals A commitment to
the practice of good dentistry respect for your freedom
to exercise sound professional judgment and quality
patient care provided in a supportive atmosphere
As a participating Cigna Dental PPO Network Dentist
you have access to many resources including a full-time
Dental Network Management Team the Cigna for
Health Care Professionals website (CignaforHCPcom)
and experienced customer service representatives You
can also take advantage of tools such as electronic
claims submission and electronic funds transfer (direct
deposit) to get paid faster than traditional methods
Please be aware that this Dental Office Reference Guide modifies your Network Dentist Agreement by reference to the guide in your Agreement To the extent there may be differences between your Agreement and this document the terms and definitions contained here will supersede those in your Agreement Please be sure to check your Network Dentist Agreement for information specific to your association with Cigna Certain policies may vary depending on state regulations
Cigna meets the dental coverage needs of millions of people Thousands of companies and other groups have chosen us to provide dental coverage to their employees Our experience and innovative philosophy mean you can count on us to continue to attract customers and maintain rewarding relationships with dentists like you
We care about your thoughts and experiences with Cigna and have an experienced team to assist you and your staff We are interested in your ideas on technology materials utilization review and quality management criteria dental health management procedures and other matters of interest to you Please feel free to share your ideas with your Network Manager Call our Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) We rely on your involvement and we value your input Thank you for participating in the Cigna PPO Network
Introduction
4PPO | Dental Office Reference Guide
800Cigna24(8002446224)
Cigna for Health Care Professionals Website (CignaforHCPcom)
Benefits for network dentists
Source of patients
By participating in the Cigna PPO Network you will gain
rsaquo The opportunity for increased patient flow and compensation from Cigna Dental Care members selecting your office
rsaquo The potential for increased patient referrals from satisfied Cigna members
rsaquo The opportunity to market your practice to many potential new patients in your area at no cost to you
With thousands of companies offering Cigna to their employees our relationships with these companies will provide you with significant opportunities to grow your patient base
Services to promote your practice
Network dentists get access to free services developed by Brighter Inc ndash now part of the Cigna family ndash to help you attract and retain patients
Brighter Profiletrade
Your free Brighter Profile highlights your practicersquos strengths and makes it easier for you to connect with Cigna Dental customers
Brighter Scoretrade
The Brighter Score is a component of the Brighter Profile It is designed to meet the needs of patients who want more information ndash while also providing you with the opportunity to maximize your Brighter Score by ensuring it is based on an accurate comprehensive and continuously growing set of information
Brighter Scheduletrade
Brighter Schedule provides convenient appointment scheduling and automated appointment reminders to patients that are Cigna Dental customers and helps improve administrative efficiency for your office
Activate your free Brighter Profile today at providersbrightercom
Brighter Profile features may vary by Cigna Dental product or customer plan
5PPO | Dental Office Reference Guide
Cigna offers multiple solutions to help you efficiently handle the administrative details of health care
Online credentialing tool
Cignarsquos online credentialing intake tool automates the credentialing process It allows you to complete sign and submit all required documents electronically This includes uploading required credentials to participate in the Cigna Network This tool drives efficiencies for your practice by eliminating the manual paper process so that you can get up and running quicker
Email DentistEnrollmentCignacom for more information or call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224)
Cigna for Health Care Professionals website (CignaforHCPcom)
CignaforHCPcom allows you to make the most of your time with the latest tools to handle the administrative tasks of dental health care It offers secure easy and convenient access to
rsaquo Check your patientsrsquo eligibility and benefit information
rsaquo View claim detail and payment information
rsaquo Enroll in electronic funds transfer and make changes
rsaquo Download and print
mdash Dental office reports including direct deposit advices (available the same day as the electronic payment)
mdash Dental office reference guides and commonly used forms
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
You can also learn more about using an electronic data interchange (EDI) vendor to eliminate paper claims and submit your claims electronically
How to register
There are two ways you can register for CignaforHCPcom
1 Register directly for the website
If your office does not have an Access Manager for the website you should go to CignaforHCPcom gt Register Now and complete the registration form
2 Gain access from your website Access Manager
If someone in your dental office is already registered for CignaforHCPcom and has been designated as the officersquos Access Manager he or she may be able to grant you immediate full and secure access The website Access Manager can assign access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Once the required information has been completed your website Access Manager will receive a temporary ID and password which can then be given to you
How to assign specific levels of access to staff
Your office can restrict or expand access to CignaforHCPcom for individual staff members as needed For example certain employees may need full access to the websitersquos functionality while others may need more limited access such as to patient eligibility and benefit details only The website Access Manager in your office can assign each user a specific level of access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Electronic claims submission
Submitting dental claims electronically can help you save time money and improve claim processing accuracy Using one of Cignarsquos EDI options allows you to send view and track claims ndash no faxing printing or mailing Everything is right on your desktop
Important note To have the immediate ability to view patientsrsquo eligibility and benefits information you must enter the dentistrsquos tax identification number and date of birth in the optional fields Otherwise you will have limited use of the website until you receive an outreach call from Cigna to verify your information and provide you with full access
Cigna Dental Health Provider Solutions
6PPO | Dental Office Reference Guide
rsaquo NEA FastAttachreg ndash Secure information exchange that is cost-effective and reliable To learn more visit National Electronic Attachment (NEA) FastAttach at nea-fastcom or call 8007825150 Discounts are available for Cigna Dental network dentists through the Cigna Network Rewards Programreg (refer to page 13 of this guide for more program details)
Electronic submission eliminates the need for duplicate x-rays or self-addressed stamped envelopes
Visit CignaforHCPcom gt Resources gt Payment Guidelines gt Electronic Claim Submission to learn more
Cigna Network Rewards visit CignaforHCPcom gt Resources gt Dental Resources gt Cigna Network Rewards Program
Save time ndash submit your claims electronically
To learn more about electronic claims submission with Cigna log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Not registered to use the website Go to CignaforHCPcom and click ldquoRegister Nowrdquo
Note For claims with no service dates the 276277 transaction will default to the process date
For questions about claims submitted through your clearinghouse contact the clearinghouse directly For questions about Cigna claim processing call Customer Service at 800Cigna24 (8002446224)
Claim inquiry and follow-up
You can inquire about the status of your claims through several methods EDI transaction 276277 the Cigna for Health Care Professionals website at CignaforHCPcom our interactive voice response system or by speaking with a customer service representative
NPI needed for EDI transactions
When you submit claims or encounters electronically or transmit other electronic transactions you must include your NPI Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008 Also the TIN (Employee Identification Number or Social Security number) of the billing provider must be submitted on electronic claims
Benefits of submitting claims to Cigna electronically
rsaquo Quicker claims submission including DHMO encounters
rsaquo Receive payments faster
rsaquo Improve claims accuracy ndash reduces errors and missing data
rsaquo Track claims received electronically which are automatically archived before processing
rsaquo Save time on resubmissions ndash incomplete or invalid claims can be reviewed and corrected online
rsaquo View track and monitor claim status reports
rsaquo Send primary and secondary coordination of benefits (COB) claims quickly reduce paperwork and eliminate printing and mailing expenses
How to submit claims electronically
EDI vendors ndash To connect electronically with an EDI vendor you only need a computer and a printer Costs vary by practice management system vendor or clearinghouse Some practice management software companies may offer free claim submissions for the first three to six months Cigna is directly connected to three vendors who provide web claim data entry for dental offices that have internet access but no office management system Visit CignacomEDIvendors to learn more
Using Payer ID 62308 you can electronically submit all claims and encounters at the same time ndash indemnity DPPO and DHMO This includes general dentistry and specialty encounters Both primary and secondary COB claims should be submitted to Cigna electronically
Submit X-rays electronically
You can submit X-rays and other attachments electronically through any of the following options
rsaquo Standard EDI 275 attachment transactions through your clearinghouse
rsaquo DentalXChange Attachment Service available free of charge for DentalXChange Claim Connecttrade subscribers
Cigna Dental Health Provider Solutions (continued)
7PPO | Dental Office Reference Guide
Benefits of enrolling in EFT
rsaquo Eliminate paper check mail delivery and handling
rsaquo Access funds on the same day of the deposit
rsaquo View a separate remittance report online for each deposit which shows the
mdash Deposit transaction
mdash Details about the claims processed
mdash Payments included in that fund transfer
rsaquo Easily reconcile payments using a single remittance tracking number
mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you
mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA
mdash Number located on the right side of the first page of your online claim payment report
Payment bulking options
Choose between two options to receive your payments
rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office
rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office
mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor
mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI
EFT enrollment guidelines
rsaquo For savings account deposits verify that your bank will support EFT
rsaquo The enrollment process typically takes two to four weeks
rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN
Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions
Electronic funds transfer and electronic remittance advice
Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear
What is EFT
rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement
rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll
rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule
Cigna Dental Health Provider Solutions (continued)
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
1PPO | Dental Office Reference Guide
Table of contents
Introduction 3
Benefits for network dentists 4
Source of patients 4
Services to promote your practice 4
Cigna Dental Health Provider Solutions 5
Online credentialing tool 5
Cigna for Health Care Professionals website (CignaforHCPcom) 5
Electronic claims submission 5
Electronic funds transfer and electronic remittance advice 7
Interactive voice response (IVR) ndash Speech recognition technology 9
Cultural competency training and resources 9
Definitions 10
Plan descriptions 12
PPO dental plans 12
Exclusive provider organization (EPO) dental plans 12
Optional programs 12
Cigna Network Rewards Program 13
Administrative policies and guidelines 14
Appointment wait time 14
Billing guidelines 15
Benefits and eligibility verification process 15
Compensation 15
Treatment plans policy 16
Non-covered services 16
Covered Services not paid by Cigna 16
Covered Services not listed in your Fee Schedule 17
Services not covered listed in Memberrsquos Certificate booklet 17
State-specific legislation for non-covered services 17
Alternate benefit provision 17
National provider identifier 18
Use of Social Security numbers 18
Claims submission 19
Who should submit claims 19
When to submit claims 19
How to submit a claim 19
Electronic claims (837) and attachments 19
Electronic remittance advice (835) 20
Real-time request transactions (270 276 278) 20
ADA codes and electronic transactions 20
Coordination of Benefits 21
Orthodontic claims 21
Invisalignreg cosmetic appliances 21
Orthodontics in progress Change in Fee Schedule or dental health professional status 21
Surgical cases 21
Cigna debit card 21
Cigna claim attachment guidelines 22
Communications 23
Directory Accuracy Legislation 23
Dental participation guidelines 24
Conditions for participation 24
The dental facility 24
General office appearance and access 24
Sterilization and infection control 24
Radiology safety 25
Environmental safety 25
Medical emergency preparedness 26
Patient recordkeeping 26
Additional Guidelines 28
Provider data changes 28
Closing the office to new members 28
Terminating your participation 28
Continued on the next page
2PPO | Dental Office Reference Guide
Language Assistance Services 29
Member complaints and surveys 31
Provider appeals and complaints 32
State-specific guidelines 33
Use of name 34
Quality and utilization management 35
Provider credentialing requirements 35
Recredentialing 35
Onsite reviews 36
Utilization management 36
Cigna Dental Oral Health Integration Program 38
Patients eligible to participate in the program 38
Provider reimbursement 39
Member reimbursement 39
Clinical policies and guidelines 40
Clinical coverage determination guidelines 40
Comprehensive periodontal evaluations 40
Emergency care 40
Infection control 40
Periodontal regenerative procedures 41
Specialty recommendations 41
Radiographs 42
Use of equipment 45
Contact information 46
Table of contents (continued)
3PPO | Dental Office Reference Guide
Welcome to the Cigna Dental PPO Network
We value your participation as a network dentist and
strive to partner with you to support your success
Our philosophy stresses the importance of preventive
dentistry and early intervention in the disease process
We believe this approach benefits both the patient
and the dentist We know that a successful managed
dental care program is built on long-term relationships
mutual rewards and common goals A commitment to
the practice of good dentistry respect for your freedom
to exercise sound professional judgment and quality
patient care provided in a supportive atmosphere
As a participating Cigna Dental PPO Network Dentist
you have access to many resources including a full-time
Dental Network Management Team the Cigna for
Health Care Professionals website (CignaforHCPcom)
and experienced customer service representatives You
can also take advantage of tools such as electronic
claims submission and electronic funds transfer (direct
deposit) to get paid faster than traditional methods
Please be aware that this Dental Office Reference Guide modifies your Network Dentist Agreement by reference to the guide in your Agreement To the extent there may be differences between your Agreement and this document the terms and definitions contained here will supersede those in your Agreement Please be sure to check your Network Dentist Agreement for information specific to your association with Cigna Certain policies may vary depending on state regulations
Cigna meets the dental coverage needs of millions of people Thousands of companies and other groups have chosen us to provide dental coverage to their employees Our experience and innovative philosophy mean you can count on us to continue to attract customers and maintain rewarding relationships with dentists like you
We care about your thoughts and experiences with Cigna and have an experienced team to assist you and your staff We are interested in your ideas on technology materials utilization review and quality management criteria dental health management procedures and other matters of interest to you Please feel free to share your ideas with your Network Manager Call our Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) We rely on your involvement and we value your input Thank you for participating in the Cigna PPO Network
Introduction
4PPO | Dental Office Reference Guide
800Cigna24(8002446224)
Cigna for Health Care Professionals Website (CignaforHCPcom)
Benefits for network dentists
Source of patients
By participating in the Cigna PPO Network you will gain
rsaquo The opportunity for increased patient flow and compensation from Cigna Dental Care members selecting your office
rsaquo The potential for increased patient referrals from satisfied Cigna members
rsaquo The opportunity to market your practice to many potential new patients in your area at no cost to you
With thousands of companies offering Cigna to their employees our relationships with these companies will provide you with significant opportunities to grow your patient base
Services to promote your practice
Network dentists get access to free services developed by Brighter Inc ndash now part of the Cigna family ndash to help you attract and retain patients
Brighter Profiletrade
Your free Brighter Profile highlights your practicersquos strengths and makes it easier for you to connect with Cigna Dental customers
Brighter Scoretrade
The Brighter Score is a component of the Brighter Profile It is designed to meet the needs of patients who want more information ndash while also providing you with the opportunity to maximize your Brighter Score by ensuring it is based on an accurate comprehensive and continuously growing set of information
Brighter Scheduletrade
Brighter Schedule provides convenient appointment scheduling and automated appointment reminders to patients that are Cigna Dental customers and helps improve administrative efficiency for your office
Activate your free Brighter Profile today at providersbrightercom
Brighter Profile features may vary by Cigna Dental product or customer plan
5PPO | Dental Office Reference Guide
Cigna offers multiple solutions to help you efficiently handle the administrative details of health care
Online credentialing tool
Cignarsquos online credentialing intake tool automates the credentialing process It allows you to complete sign and submit all required documents electronically This includes uploading required credentials to participate in the Cigna Network This tool drives efficiencies for your practice by eliminating the manual paper process so that you can get up and running quicker
Email DentistEnrollmentCignacom for more information or call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224)
Cigna for Health Care Professionals website (CignaforHCPcom)
CignaforHCPcom allows you to make the most of your time with the latest tools to handle the administrative tasks of dental health care It offers secure easy and convenient access to
rsaquo Check your patientsrsquo eligibility and benefit information
rsaquo View claim detail and payment information
rsaquo Enroll in electronic funds transfer and make changes
rsaquo Download and print
mdash Dental office reports including direct deposit advices (available the same day as the electronic payment)
mdash Dental office reference guides and commonly used forms
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
You can also learn more about using an electronic data interchange (EDI) vendor to eliminate paper claims and submit your claims electronically
How to register
There are two ways you can register for CignaforHCPcom
1 Register directly for the website
If your office does not have an Access Manager for the website you should go to CignaforHCPcom gt Register Now and complete the registration form
2 Gain access from your website Access Manager
If someone in your dental office is already registered for CignaforHCPcom and has been designated as the officersquos Access Manager he or she may be able to grant you immediate full and secure access The website Access Manager can assign access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Once the required information has been completed your website Access Manager will receive a temporary ID and password which can then be given to you
How to assign specific levels of access to staff
Your office can restrict or expand access to CignaforHCPcom for individual staff members as needed For example certain employees may need full access to the websitersquos functionality while others may need more limited access such as to patient eligibility and benefit details only The website Access Manager in your office can assign each user a specific level of access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Electronic claims submission
Submitting dental claims electronically can help you save time money and improve claim processing accuracy Using one of Cignarsquos EDI options allows you to send view and track claims ndash no faxing printing or mailing Everything is right on your desktop
Important note To have the immediate ability to view patientsrsquo eligibility and benefits information you must enter the dentistrsquos tax identification number and date of birth in the optional fields Otherwise you will have limited use of the website until you receive an outreach call from Cigna to verify your information and provide you with full access
Cigna Dental Health Provider Solutions
6PPO | Dental Office Reference Guide
rsaquo NEA FastAttachreg ndash Secure information exchange that is cost-effective and reliable To learn more visit National Electronic Attachment (NEA) FastAttach at nea-fastcom or call 8007825150 Discounts are available for Cigna Dental network dentists through the Cigna Network Rewards Programreg (refer to page 13 of this guide for more program details)
Electronic submission eliminates the need for duplicate x-rays or self-addressed stamped envelopes
Visit CignaforHCPcom gt Resources gt Payment Guidelines gt Electronic Claim Submission to learn more
Cigna Network Rewards visit CignaforHCPcom gt Resources gt Dental Resources gt Cigna Network Rewards Program
Save time ndash submit your claims electronically
To learn more about electronic claims submission with Cigna log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Not registered to use the website Go to CignaforHCPcom and click ldquoRegister Nowrdquo
Note For claims with no service dates the 276277 transaction will default to the process date
For questions about claims submitted through your clearinghouse contact the clearinghouse directly For questions about Cigna claim processing call Customer Service at 800Cigna24 (8002446224)
Claim inquiry and follow-up
You can inquire about the status of your claims through several methods EDI transaction 276277 the Cigna for Health Care Professionals website at CignaforHCPcom our interactive voice response system or by speaking with a customer service representative
NPI needed for EDI transactions
When you submit claims or encounters electronically or transmit other electronic transactions you must include your NPI Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008 Also the TIN (Employee Identification Number or Social Security number) of the billing provider must be submitted on electronic claims
Benefits of submitting claims to Cigna electronically
rsaquo Quicker claims submission including DHMO encounters
rsaquo Receive payments faster
rsaquo Improve claims accuracy ndash reduces errors and missing data
rsaquo Track claims received electronically which are automatically archived before processing
rsaquo Save time on resubmissions ndash incomplete or invalid claims can be reviewed and corrected online
rsaquo View track and monitor claim status reports
rsaquo Send primary and secondary coordination of benefits (COB) claims quickly reduce paperwork and eliminate printing and mailing expenses
How to submit claims electronically
EDI vendors ndash To connect electronically with an EDI vendor you only need a computer and a printer Costs vary by practice management system vendor or clearinghouse Some practice management software companies may offer free claim submissions for the first three to six months Cigna is directly connected to three vendors who provide web claim data entry for dental offices that have internet access but no office management system Visit CignacomEDIvendors to learn more
Using Payer ID 62308 you can electronically submit all claims and encounters at the same time ndash indemnity DPPO and DHMO This includes general dentistry and specialty encounters Both primary and secondary COB claims should be submitted to Cigna electronically
Submit X-rays electronically
You can submit X-rays and other attachments electronically through any of the following options
rsaquo Standard EDI 275 attachment transactions through your clearinghouse
rsaquo DentalXChange Attachment Service available free of charge for DentalXChange Claim Connecttrade subscribers
Cigna Dental Health Provider Solutions (continued)
7PPO | Dental Office Reference Guide
Benefits of enrolling in EFT
rsaquo Eliminate paper check mail delivery and handling
rsaquo Access funds on the same day of the deposit
rsaquo View a separate remittance report online for each deposit which shows the
mdash Deposit transaction
mdash Details about the claims processed
mdash Payments included in that fund transfer
rsaquo Easily reconcile payments using a single remittance tracking number
mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you
mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA
mdash Number located on the right side of the first page of your online claim payment report
Payment bulking options
Choose between two options to receive your payments
rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office
rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office
mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor
mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI
EFT enrollment guidelines
rsaquo For savings account deposits verify that your bank will support EFT
rsaquo The enrollment process typically takes two to four weeks
rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN
Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions
Electronic funds transfer and electronic remittance advice
Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear
What is EFT
rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement
rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll
rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule
Cigna Dental Health Provider Solutions (continued)
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
2PPO | Dental Office Reference Guide
Language Assistance Services 29
Member complaints and surveys 31
Provider appeals and complaints 32
State-specific guidelines 33
Use of name 34
Quality and utilization management 35
Provider credentialing requirements 35
Recredentialing 35
Onsite reviews 36
Utilization management 36
Cigna Dental Oral Health Integration Program 38
Patients eligible to participate in the program 38
Provider reimbursement 39
Member reimbursement 39
Clinical policies and guidelines 40
Clinical coverage determination guidelines 40
Comprehensive periodontal evaluations 40
Emergency care 40
Infection control 40
Periodontal regenerative procedures 41
Specialty recommendations 41
Radiographs 42
Use of equipment 45
Contact information 46
Table of contents (continued)
3PPO | Dental Office Reference Guide
Welcome to the Cigna Dental PPO Network
We value your participation as a network dentist and
strive to partner with you to support your success
Our philosophy stresses the importance of preventive
dentistry and early intervention in the disease process
We believe this approach benefits both the patient
and the dentist We know that a successful managed
dental care program is built on long-term relationships
mutual rewards and common goals A commitment to
the practice of good dentistry respect for your freedom
to exercise sound professional judgment and quality
patient care provided in a supportive atmosphere
As a participating Cigna Dental PPO Network Dentist
you have access to many resources including a full-time
Dental Network Management Team the Cigna for
Health Care Professionals website (CignaforHCPcom)
and experienced customer service representatives You
can also take advantage of tools such as electronic
claims submission and electronic funds transfer (direct
deposit) to get paid faster than traditional methods
Please be aware that this Dental Office Reference Guide modifies your Network Dentist Agreement by reference to the guide in your Agreement To the extent there may be differences between your Agreement and this document the terms and definitions contained here will supersede those in your Agreement Please be sure to check your Network Dentist Agreement for information specific to your association with Cigna Certain policies may vary depending on state regulations
Cigna meets the dental coverage needs of millions of people Thousands of companies and other groups have chosen us to provide dental coverage to their employees Our experience and innovative philosophy mean you can count on us to continue to attract customers and maintain rewarding relationships with dentists like you
We care about your thoughts and experiences with Cigna and have an experienced team to assist you and your staff We are interested in your ideas on technology materials utilization review and quality management criteria dental health management procedures and other matters of interest to you Please feel free to share your ideas with your Network Manager Call our Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) We rely on your involvement and we value your input Thank you for participating in the Cigna PPO Network
Introduction
4PPO | Dental Office Reference Guide
800Cigna24(8002446224)
Cigna for Health Care Professionals Website (CignaforHCPcom)
Benefits for network dentists
Source of patients
By participating in the Cigna PPO Network you will gain
rsaquo The opportunity for increased patient flow and compensation from Cigna Dental Care members selecting your office
rsaquo The potential for increased patient referrals from satisfied Cigna members
rsaquo The opportunity to market your practice to many potential new patients in your area at no cost to you
With thousands of companies offering Cigna to their employees our relationships with these companies will provide you with significant opportunities to grow your patient base
Services to promote your practice
Network dentists get access to free services developed by Brighter Inc ndash now part of the Cigna family ndash to help you attract and retain patients
Brighter Profiletrade
Your free Brighter Profile highlights your practicersquos strengths and makes it easier for you to connect with Cigna Dental customers
Brighter Scoretrade
The Brighter Score is a component of the Brighter Profile It is designed to meet the needs of patients who want more information ndash while also providing you with the opportunity to maximize your Brighter Score by ensuring it is based on an accurate comprehensive and continuously growing set of information
Brighter Scheduletrade
Brighter Schedule provides convenient appointment scheduling and automated appointment reminders to patients that are Cigna Dental customers and helps improve administrative efficiency for your office
Activate your free Brighter Profile today at providersbrightercom
Brighter Profile features may vary by Cigna Dental product or customer plan
5PPO | Dental Office Reference Guide
Cigna offers multiple solutions to help you efficiently handle the administrative details of health care
Online credentialing tool
Cignarsquos online credentialing intake tool automates the credentialing process It allows you to complete sign and submit all required documents electronically This includes uploading required credentials to participate in the Cigna Network This tool drives efficiencies for your practice by eliminating the manual paper process so that you can get up and running quicker
Email DentistEnrollmentCignacom for more information or call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224)
Cigna for Health Care Professionals website (CignaforHCPcom)
CignaforHCPcom allows you to make the most of your time with the latest tools to handle the administrative tasks of dental health care It offers secure easy and convenient access to
rsaquo Check your patientsrsquo eligibility and benefit information
rsaquo View claim detail and payment information
rsaquo Enroll in electronic funds transfer and make changes
rsaquo Download and print
mdash Dental office reports including direct deposit advices (available the same day as the electronic payment)
mdash Dental office reference guides and commonly used forms
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
You can also learn more about using an electronic data interchange (EDI) vendor to eliminate paper claims and submit your claims electronically
How to register
There are two ways you can register for CignaforHCPcom
1 Register directly for the website
If your office does not have an Access Manager for the website you should go to CignaforHCPcom gt Register Now and complete the registration form
2 Gain access from your website Access Manager
If someone in your dental office is already registered for CignaforHCPcom and has been designated as the officersquos Access Manager he or she may be able to grant you immediate full and secure access The website Access Manager can assign access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Once the required information has been completed your website Access Manager will receive a temporary ID and password which can then be given to you
How to assign specific levels of access to staff
Your office can restrict or expand access to CignaforHCPcom for individual staff members as needed For example certain employees may need full access to the websitersquos functionality while others may need more limited access such as to patient eligibility and benefit details only The website Access Manager in your office can assign each user a specific level of access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Electronic claims submission
Submitting dental claims electronically can help you save time money and improve claim processing accuracy Using one of Cignarsquos EDI options allows you to send view and track claims ndash no faxing printing or mailing Everything is right on your desktop
Important note To have the immediate ability to view patientsrsquo eligibility and benefits information you must enter the dentistrsquos tax identification number and date of birth in the optional fields Otherwise you will have limited use of the website until you receive an outreach call from Cigna to verify your information and provide you with full access
Cigna Dental Health Provider Solutions
6PPO | Dental Office Reference Guide
rsaquo NEA FastAttachreg ndash Secure information exchange that is cost-effective and reliable To learn more visit National Electronic Attachment (NEA) FastAttach at nea-fastcom or call 8007825150 Discounts are available for Cigna Dental network dentists through the Cigna Network Rewards Programreg (refer to page 13 of this guide for more program details)
Electronic submission eliminates the need for duplicate x-rays or self-addressed stamped envelopes
Visit CignaforHCPcom gt Resources gt Payment Guidelines gt Electronic Claim Submission to learn more
Cigna Network Rewards visit CignaforHCPcom gt Resources gt Dental Resources gt Cigna Network Rewards Program
Save time ndash submit your claims electronically
To learn more about electronic claims submission with Cigna log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Not registered to use the website Go to CignaforHCPcom and click ldquoRegister Nowrdquo
Note For claims with no service dates the 276277 transaction will default to the process date
For questions about claims submitted through your clearinghouse contact the clearinghouse directly For questions about Cigna claim processing call Customer Service at 800Cigna24 (8002446224)
Claim inquiry and follow-up
You can inquire about the status of your claims through several methods EDI transaction 276277 the Cigna for Health Care Professionals website at CignaforHCPcom our interactive voice response system or by speaking with a customer service representative
NPI needed for EDI transactions
When you submit claims or encounters electronically or transmit other electronic transactions you must include your NPI Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008 Also the TIN (Employee Identification Number or Social Security number) of the billing provider must be submitted on electronic claims
Benefits of submitting claims to Cigna electronically
rsaquo Quicker claims submission including DHMO encounters
rsaquo Receive payments faster
rsaquo Improve claims accuracy ndash reduces errors and missing data
rsaquo Track claims received electronically which are automatically archived before processing
rsaquo Save time on resubmissions ndash incomplete or invalid claims can be reviewed and corrected online
rsaquo View track and monitor claim status reports
rsaquo Send primary and secondary coordination of benefits (COB) claims quickly reduce paperwork and eliminate printing and mailing expenses
How to submit claims electronically
EDI vendors ndash To connect electronically with an EDI vendor you only need a computer and a printer Costs vary by practice management system vendor or clearinghouse Some practice management software companies may offer free claim submissions for the first three to six months Cigna is directly connected to three vendors who provide web claim data entry for dental offices that have internet access but no office management system Visit CignacomEDIvendors to learn more
Using Payer ID 62308 you can electronically submit all claims and encounters at the same time ndash indemnity DPPO and DHMO This includes general dentistry and specialty encounters Both primary and secondary COB claims should be submitted to Cigna electronically
Submit X-rays electronically
You can submit X-rays and other attachments electronically through any of the following options
rsaquo Standard EDI 275 attachment transactions through your clearinghouse
rsaquo DentalXChange Attachment Service available free of charge for DentalXChange Claim Connecttrade subscribers
Cigna Dental Health Provider Solutions (continued)
7PPO | Dental Office Reference Guide
Benefits of enrolling in EFT
rsaquo Eliminate paper check mail delivery and handling
rsaquo Access funds on the same day of the deposit
rsaquo View a separate remittance report online for each deposit which shows the
mdash Deposit transaction
mdash Details about the claims processed
mdash Payments included in that fund transfer
rsaquo Easily reconcile payments using a single remittance tracking number
mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you
mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA
mdash Number located on the right side of the first page of your online claim payment report
Payment bulking options
Choose between two options to receive your payments
rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office
rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office
mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor
mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI
EFT enrollment guidelines
rsaquo For savings account deposits verify that your bank will support EFT
rsaquo The enrollment process typically takes two to four weeks
rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN
Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions
Electronic funds transfer and electronic remittance advice
Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear
What is EFT
rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement
rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll
rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule
Cigna Dental Health Provider Solutions (continued)
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
3PPO | Dental Office Reference Guide
Welcome to the Cigna Dental PPO Network
We value your participation as a network dentist and
strive to partner with you to support your success
Our philosophy stresses the importance of preventive
dentistry and early intervention in the disease process
We believe this approach benefits both the patient
and the dentist We know that a successful managed
dental care program is built on long-term relationships
mutual rewards and common goals A commitment to
the practice of good dentistry respect for your freedom
to exercise sound professional judgment and quality
patient care provided in a supportive atmosphere
As a participating Cigna Dental PPO Network Dentist
you have access to many resources including a full-time
Dental Network Management Team the Cigna for
Health Care Professionals website (CignaforHCPcom)
and experienced customer service representatives You
can also take advantage of tools such as electronic
claims submission and electronic funds transfer (direct
deposit) to get paid faster than traditional methods
Please be aware that this Dental Office Reference Guide modifies your Network Dentist Agreement by reference to the guide in your Agreement To the extent there may be differences between your Agreement and this document the terms and definitions contained here will supersede those in your Agreement Please be sure to check your Network Dentist Agreement for information specific to your association with Cigna Certain policies may vary depending on state regulations
Cigna meets the dental coverage needs of millions of people Thousands of companies and other groups have chosen us to provide dental coverage to their employees Our experience and innovative philosophy mean you can count on us to continue to attract customers and maintain rewarding relationships with dentists like you
We care about your thoughts and experiences with Cigna and have an experienced team to assist you and your staff We are interested in your ideas on technology materials utilization review and quality management criteria dental health management procedures and other matters of interest to you Please feel free to share your ideas with your Network Manager Call our Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) We rely on your involvement and we value your input Thank you for participating in the Cigna PPO Network
Introduction
4PPO | Dental Office Reference Guide
800Cigna24(8002446224)
Cigna for Health Care Professionals Website (CignaforHCPcom)
Benefits for network dentists
Source of patients
By participating in the Cigna PPO Network you will gain
rsaquo The opportunity for increased patient flow and compensation from Cigna Dental Care members selecting your office
rsaquo The potential for increased patient referrals from satisfied Cigna members
rsaquo The opportunity to market your practice to many potential new patients in your area at no cost to you
With thousands of companies offering Cigna to their employees our relationships with these companies will provide you with significant opportunities to grow your patient base
Services to promote your practice
Network dentists get access to free services developed by Brighter Inc ndash now part of the Cigna family ndash to help you attract and retain patients
Brighter Profiletrade
Your free Brighter Profile highlights your practicersquos strengths and makes it easier for you to connect with Cigna Dental customers
Brighter Scoretrade
The Brighter Score is a component of the Brighter Profile It is designed to meet the needs of patients who want more information ndash while also providing you with the opportunity to maximize your Brighter Score by ensuring it is based on an accurate comprehensive and continuously growing set of information
Brighter Scheduletrade
Brighter Schedule provides convenient appointment scheduling and automated appointment reminders to patients that are Cigna Dental customers and helps improve administrative efficiency for your office
Activate your free Brighter Profile today at providersbrightercom
Brighter Profile features may vary by Cigna Dental product or customer plan
5PPO | Dental Office Reference Guide
Cigna offers multiple solutions to help you efficiently handle the administrative details of health care
Online credentialing tool
Cignarsquos online credentialing intake tool automates the credentialing process It allows you to complete sign and submit all required documents electronically This includes uploading required credentials to participate in the Cigna Network This tool drives efficiencies for your practice by eliminating the manual paper process so that you can get up and running quicker
Email DentistEnrollmentCignacom for more information or call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224)
Cigna for Health Care Professionals website (CignaforHCPcom)
CignaforHCPcom allows you to make the most of your time with the latest tools to handle the administrative tasks of dental health care It offers secure easy and convenient access to
rsaquo Check your patientsrsquo eligibility and benefit information
rsaquo View claim detail and payment information
rsaquo Enroll in electronic funds transfer and make changes
rsaquo Download and print
mdash Dental office reports including direct deposit advices (available the same day as the electronic payment)
mdash Dental office reference guides and commonly used forms
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
You can also learn more about using an electronic data interchange (EDI) vendor to eliminate paper claims and submit your claims electronically
How to register
There are two ways you can register for CignaforHCPcom
1 Register directly for the website
If your office does not have an Access Manager for the website you should go to CignaforHCPcom gt Register Now and complete the registration form
2 Gain access from your website Access Manager
If someone in your dental office is already registered for CignaforHCPcom and has been designated as the officersquos Access Manager he or she may be able to grant you immediate full and secure access The website Access Manager can assign access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Once the required information has been completed your website Access Manager will receive a temporary ID and password which can then be given to you
How to assign specific levels of access to staff
Your office can restrict or expand access to CignaforHCPcom for individual staff members as needed For example certain employees may need full access to the websitersquos functionality while others may need more limited access such as to patient eligibility and benefit details only The website Access Manager in your office can assign each user a specific level of access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Electronic claims submission
Submitting dental claims electronically can help you save time money and improve claim processing accuracy Using one of Cignarsquos EDI options allows you to send view and track claims ndash no faxing printing or mailing Everything is right on your desktop
Important note To have the immediate ability to view patientsrsquo eligibility and benefits information you must enter the dentistrsquos tax identification number and date of birth in the optional fields Otherwise you will have limited use of the website until you receive an outreach call from Cigna to verify your information and provide you with full access
Cigna Dental Health Provider Solutions
6PPO | Dental Office Reference Guide
rsaquo NEA FastAttachreg ndash Secure information exchange that is cost-effective and reliable To learn more visit National Electronic Attachment (NEA) FastAttach at nea-fastcom or call 8007825150 Discounts are available for Cigna Dental network dentists through the Cigna Network Rewards Programreg (refer to page 13 of this guide for more program details)
Electronic submission eliminates the need for duplicate x-rays or self-addressed stamped envelopes
Visit CignaforHCPcom gt Resources gt Payment Guidelines gt Electronic Claim Submission to learn more
Cigna Network Rewards visit CignaforHCPcom gt Resources gt Dental Resources gt Cigna Network Rewards Program
Save time ndash submit your claims electronically
To learn more about electronic claims submission with Cigna log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Not registered to use the website Go to CignaforHCPcom and click ldquoRegister Nowrdquo
Note For claims with no service dates the 276277 transaction will default to the process date
For questions about claims submitted through your clearinghouse contact the clearinghouse directly For questions about Cigna claim processing call Customer Service at 800Cigna24 (8002446224)
Claim inquiry and follow-up
You can inquire about the status of your claims through several methods EDI transaction 276277 the Cigna for Health Care Professionals website at CignaforHCPcom our interactive voice response system or by speaking with a customer service representative
NPI needed for EDI transactions
When you submit claims or encounters electronically or transmit other electronic transactions you must include your NPI Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008 Also the TIN (Employee Identification Number or Social Security number) of the billing provider must be submitted on electronic claims
Benefits of submitting claims to Cigna electronically
rsaquo Quicker claims submission including DHMO encounters
rsaquo Receive payments faster
rsaquo Improve claims accuracy ndash reduces errors and missing data
rsaquo Track claims received electronically which are automatically archived before processing
rsaquo Save time on resubmissions ndash incomplete or invalid claims can be reviewed and corrected online
rsaquo View track and monitor claim status reports
rsaquo Send primary and secondary coordination of benefits (COB) claims quickly reduce paperwork and eliminate printing and mailing expenses
How to submit claims electronically
EDI vendors ndash To connect electronically with an EDI vendor you only need a computer and a printer Costs vary by practice management system vendor or clearinghouse Some practice management software companies may offer free claim submissions for the first three to six months Cigna is directly connected to three vendors who provide web claim data entry for dental offices that have internet access but no office management system Visit CignacomEDIvendors to learn more
Using Payer ID 62308 you can electronically submit all claims and encounters at the same time ndash indemnity DPPO and DHMO This includes general dentistry and specialty encounters Both primary and secondary COB claims should be submitted to Cigna electronically
Submit X-rays electronically
You can submit X-rays and other attachments electronically through any of the following options
rsaquo Standard EDI 275 attachment transactions through your clearinghouse
rsaquo DentalXChange Attachment Service available free of charge for DentalXChange Claim Connecttrade subscribers
Cigna Dental Health Provider Solutions (continued)
7PPO | Dental Office Reference Guide
Benefits of enrolling in EFT
rsaquo Eliminate paper check mail delivery and handling
rsaquo Access funds on the same day of the deposit
rsaquo View a separate remittance report online for each deposit which shows the
mdash Deposit transaction
mdash Details about the claims processed
mdash Payments included in that fund transfer
rsaquo Easily reconcile payments using a single remittance tracking number
mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you
mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA
mdash Number located on the right side of the first page of your online claim payment report
Payment bulking options
Choose between two options to receive your payments
rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office
rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office
mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor
mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI
EFT enrollment guidelines
rsaquo For savings account deposits verify that your bank will support EFT
rsaquo The enrollment process typically takes two to four weeks
rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN
Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions
Electronic funds transfer and electronic remittance advice
Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear
What is EFT
rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement
rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll
rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule
Cigna Dental Health Provider Solutions (continued)
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
4PPO | Dental Office Reference Guide
800Cigna24(8002446224)
Cigna for Health Care Professionals Website (CignaforHCPcom)
Benefits for network dentists
Source of patients
By participating in the Cigna PPO Network you will gain
rsaquo The opportunity for increased patient flow and compensation from Cigna Dental Care members selecting your office
rsaquo The potential for increased patient referrals from satisfied Cigna members
rsaquo The opportunity to market your practice to many potential new patients in your area at no cost to you
With thousands of companies offering Cigna to their employees our relationships with these companies will provide you with significant opportunities to grow your patient base
Services to promote your practice
Network dentists get access to free services developed by Brighter Inc ndash now part of the Cigna family ndash to help you attract and retain patients
Brighter Profiletrade
Your free Brighter Profile highlights your practicersquos strengths and makes it easier for you to connect with Cigna Dental customers
Brighter Scoretrade
The Brighter Score is a component of the Brighter Profile It is designed to meet the needs of patients who want more information ndash while also providing you with the opportunity to maximize your Brighter Score by ensuring it is based on an accurate comprehensive and continuously growing set of information
Brighter Scheduletrade
Brighter Schedule provides convenient appointment scheduling and automated appointment reminders to patients that are Cigna Dental customers and helps improve administrative efficiency for your office
Activate your free Brighter Profile today at providersbrightercom
Brighter Profile features may vary by Cigna Dental product or customer plan
5PPO | Dental Office Reference Guide
Cigna offers multiple solutions to help you efficiently handle the administrative details of health care
Online credentialing tool
Cignarsquos online credentialing intake tool automates the credentialing process It allows you to complete sign and submit all required documents electronically This includes uploading required credentials to participate in the Cigna Network This tool drives efficiencies for your practice by eliminating the manual paper process so that you can get up and running quicker
Email DentistEnrollmentCignacom for more information or call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224)
Cigna for Health Care Professionals website (CignaforHCPcom)
CignaforHCPcom allows you to make the most of your time with the latest tools to handle the administrative tasks of dental health care It offers secure easy and convenient access to
rsaquo Check your patientsrsquo eligibility and benefit information
rsaquo View claim detail and payment information
rsaquo Enroll in electronic funds transfer and make changes
rsaquo Download and print
mdash Dental office reports including direct deposit advices (available the same day as the electronic payment)
mdash Dental office reference guides and commonly used forms
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
You can also learn more about using an electronic data interchange (EDI) vendor to eliminate paper claims and submit your claims electronically
How to register
There are two ways you can register for CignaforHCPcom
1 Register directly for the website
If your office does not have an Access Manager for the website you should go to CignaforHCPcom gt Register Now and complete the registration form
2 Gain access from your website Access Manager
If someone in your dental office is already registered for CignaforHCPcom and has been designated as the officersquos Access Manager he or she may be able to grant you immediate full and secure access The website Access Manager can assign access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Once the required information has been completed your website Access Manager will receive a temporary ID and password which can then be given to you
How to assign specific levels of access to staff
Your office can restrict or expand access to CignaforHCPcom for individual staff members as needed For example certain employees may need full access to the websitersquos functionality while others may need more limited access such as to patient eligibility and benefit details only The website Access Manager in your office can assign each user a specific level of access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Electronic claims submission
Submitting dental claims electronically can help you save time money and improve claim processing accuracy Using one of Cignarsquos EDI options allows you to send view and track claims ndash no faxing printing or mailing Everything is right on your desktop
Important note To have the immediate ability to view patientsrsquo eligibility and benefits information you must enter the dentistrsquos tax identification number and date of birth in the optional fields Otherwise you will have limited use of the website until you receive an outreach call from Cigna to verify your information and provide you with full access
Cigna Dental Health Provider Solutions
6PPO | Dental Office Reference Guide
rsaquo NEA FastAttachreg ndash Secure information exchange that is cost-effective and reliable To learn more visit National Electronic Attachment (NEA) FastAttach at nea-fastcom or call 8007825150 Discounts are available for Cigna Dental network dentists through the Cigna Network Rewards Programreg (refer to page 13 of this guide for more program details)
Electronic submission eliminates the need for duplicate x-rays or self-addressed stamped envelopes
Visit CignaforHCPcom gt Resources gt Payment Guidelines gt Electronic Claim Submission to learn more
Cigna Network Rewards visit CignaforHCPcom gt Resources gt Dental Resources gt Cigna Network Rewards Program
Save time ndash submit your claims electronically
To learn more about electronic claims submission with Cigna log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Not registered to use the website Go to CignaforHCPcom and click ldquoRegister Nowrdquo
Note For claims with no service dates the 276277 transaction will default to the process date
For questions about claims submitted through your clearinghouse contact the clearinghouse directly For questions about Cigna claim processing call Customer Service at 800Cigna24 (8002446224)
Claim inquiry and follow-up
You can inquire about the status of your claims through several methods EDI transaction 276277 the Cigna for Health Care Professionals website at CignaforHCPcom our interactive voice response system or by speaking with a customer service representative
NPI needed for EDI transactions
When you submit claims or encounters electronically or transmit other electronic transactions you must include your NPI Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008 Also the TIN (Employee Identification Number or Social Security number) of the billing provider must be submitted on electronic claims
Benefits of submitting claims to Cigna electronically
rsaquo Quicker claims submission including DHMO encounters
rsaquo Receive payments faster
rsaquo Improve claims accuracy ndash reduces errors and missing data
rsaquo Track claims received electronically which are automatically archived before processing
rsaquo Save time on resubmissions ndash incomplete or invalid claims can be reviewed and corrected online
rsaquo View track and monitor claim status reports
rsaquo Send primary and secondary coordination of benefits (COB) claims quickly reduce paperwork and eliminate printing and mailing expenses
How to submit claims electronically
EDI vendors ndash To connect electronically with an EDI vendor you only need a computer and a printer Costs vary by practice management system vendor or clearinghouse Some practice management software companies may offer free claim submissions for the first three to six months Cigna is directly connected to three vendors who provide web claim data entry for dental offices that have internet access but no office management system Visit CignacomEDIvendors to learn more
Using Payer ID 62308 you can electronically submit all claims and encounters at the same time ndash indemnity DPPO and DHMO This includes general dentistry and specialty encounters Both primary and secondary COB claims should be submitted to Cigna electronically
Submit X-rays electronically
You can submit X-rays and other attachments electronically through any of the following options
rsaquo Standard EDI 275 attachment transactions through your clearinghouse
rsaquo DentalXChange Attachment Service available free of charge for DentalXChange Claim Connecttrade subscribers
Cigna Dental Health Provider Solutions (continued)
7PPO | Dental Office Reference Guide
Benefits of enrolling in EFT
rsaquo Eliminate paper check mail delivery and handling
rsaquo Access funds on the same day of the deposit
rsaquo View a separate remittance report online for each deposit which shows the
mdash Deposit transaction
mdash Details about the claims processed
mdash Payments included in that fund transfer
rsaquo Easily reconcile payments using a single remittance tracking number
mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you
mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA
mdash Number located on the right side of the first page of your online claim payment report
Payment bulking options
Choose between two options to receive your payments
rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office
rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office
mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor
mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI
EFT enrollment guidelines
rsaquo For savings account deposits verify that your bank will support EFT
rsaquo The enrollment process typically takes two to four weeks
rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN
Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions
Electronic funds transfer and electronic remittance advice
Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear
What is EFT
rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement
rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll
rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule
Cigna Dental Health Provider Solutions (continued)
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
5PPO | Dental Office Reference Guide
Cigna offers multiple solutions to help you efficiently handle the administrative details of health care
Online credentialing tool
Cignarsquos online credentialing intake tool automates the credentialing process It allows you to complete sign and submit all required documents electronically This includes uploading required credentials to participate in the Cigna Network This tool drives efficiencies for your practice by eliminating the manual paper process so that you can get up and running quicker
Email DentistEnrollmentCignacom for more information or call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224)
Cigna for Health Care Professionals website (CignaforHCPcom)
CignaforHCPcom allows you to make the most of your time with the latest tools to handle the administrative tasks of dental health care It offers secure easy and convenient access to
rsaquo Check your patientsrsquo eligibility and benefit information
rsaquo View claim detail and payment information
rsaquo Enroll in electronic funds transfer and make changes
rsaquo Download and print
mdash Dental office reports including direct deposit advices (available the same day as the electronic payment)
mdash Dental office reference guides and commonly used forms
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
You can also learn more about using an electronic data interchange (EDI) vendor to eliminate paper claims and submit your claims electronically
How to register
There are two ways you can register for CignaforHCPcom
1 Register directly for the website
If your office does not have an Access Manager for the website you should go to CignaforHCPcom gt Register Now and complete the registration form
2 Gain access from your website Access Manager
If someone in your dental office is already registered for CignaforHCPcom and has been designated as the officersquos Access Manager he or she may be able to grant you immediate full and secure access The website Access Manager can assign access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Once the required information has been completed your website Access Manager will receive a temporary ID and password which can then be given to you
How to assign specific levels of access to staff
Your office can restrict or expand access to CignaforHCPcom for individual staff members as needed For example certain employees may need full access to the websitersquos functionality while others may need more limited access such as to patient eligibility and benefit details only The website Access Manager in your office can assign each user a specific level of access by logging in to CignaforHCPcom gt Working with Cigna gt Modify Existing UsersAdd New Users
Electronic claims submission
Submitting dental claims electronically can help you save time money and improve claim processing accuracy Using one of Cignarsquos EDI options allows you to send view and track claims ndash no faxing printing or mailing Everything is right on your desktop
Important note To have the immediate ability to view patientsrsquo eligibility and benefits information you must enter the dentistrsquos tax identification number and date of birth in the optional fields Otherwise you will have limited use of the website until you receive an outreach call from Cigna to verify your information and provide you with full access
Cigna Dental Health Provider Solutions
6PPO | Dental Office Reference Guide
rsaquo NEA FastAttachreg ndash Secure information exchange that is cost-effective and reliable To learn more visit National Electronic Attachment (NEA) FastAttach at nea-fastcom or call 8007825150 Discounts are available for Cigna Dental network dentists through the Cigna Network Rewards Programreg (refer to page 13 of this guide for more program details)
Electronic submission eliminates the need for duplicate x-rays or self-addressed stamped envelopes
Visit CignaforHCPcom gt Resources gt Payment Guidelines gt Electronic Claim Submission to learn more
Cigna Network Rewards visit CignaforHCPcom gt Resources gt Dental Resources gt Cigna Network Rewards Program
Save time ndash submit your claims electronically
To learn more about electronic claims submission with Cigna log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Not registered to use the website Go to CignaforHCPcom and click ldquoRegister Nowrdquo
Note For claims with no service dates the 276277 transaction will default to the process date
For questions about claims submitted through your clearinghouse contact the clearinghouse directly For questions about Cigna claim processing call Customer Service at 800Cigna24 (8002446224)
Claim inquiry and follow-up
You can inquire about the status of your claims through several methods EDI transaction 276277 the Cigna for Health Care Professionals website at CignaforHCPcom our interactive voice response system or by speaking with a customer service representative
NPI needed for EDI transactions
When you submit claims or encounters electronically or transmit other electronic transactions you must include your NPI Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008 Also the TIN (Employee Identification Number or Social Security number) of the billing provider must be submitted on electronic claims
Benefits of submitting claims to Cigna electronically
rsaquo Quicker claims submission including DHMO encounters
rsaquo Receive payments faster
rsaquo Improve claims accuracy ndash reduces errors and missing data
rsaquo Track claims received electronically which are automatically archived before processing
rsaquo Save time on resubmissions ndash incomplete or invalid claims can be reviewed and corrected online
rsaquo View track and monitor claim status reports
rsaquo Send primary and secondary coordination of benefits (COB) claims quickly reduce paperwork and eliminate printing and mailing expenses
How to submit claims electronically
EDI vendors ndash To connect electronically with an EDI vendor you only need a computer and a printer Costs vary by practice management system vendor or clearinghouse Some practice management software companies may offer free claim submissions for the first three to six months Cigna is directly connected to three vendors who provide web claim data entry for dental offices that have internet access but no office management system Visit CignacomEDIvendors to learn more
Using Payer ID 62308 you can electronically submit all claims and encounters at the same time ndash indemnity DPPO and DHMO This includes general dentistry and specialty encounters Both primary and secondary COB claims should be submitted to Cigna electronically
Submit X-rays electronically
You can submit X-rays and other attachments electronically through any of the following options
rsaquo Standard EDI 275 attachment transactions through your clearinghouse
rsaquo DentalXChange Attachment Service available free of charge for DentalXChange Claim Connecttrade subscribers
Cigna Dental Health Provider Solutions (continued)
7PPO | Dental Office Reference Guide
Benefits of enrolling in EFT
rsaquo Eliminate paper check mail delivery and handling
rsaquo Access funds on the same day of the deposit
rsaquo View a separate remittance report online for each deposit which shows the
mdash Deposit transaction
mdash Details about the claims processed
mdash Payments included in that fund transfer
rsaquo Easily reconcile payments using a single remittance tracking number
mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you
mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA
mdash Number located on the right side of the first page of your online claim payment report
Payment bulking options
Choose between two options to receive your payments
rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office
rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office
mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor
mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI
EFT enrollment guidelines
rsaquo For savings account deposits verify that your bank will support EFT
rsaquo The enrollment process typically takes two to four weeks
rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN
Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions
Electronic funds transfer and electronic remittance advice
Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear
What is EFT
rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement
rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll
rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule
Cigna Dental Health Provider Solutions (continued)
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
6PPO | Dental Office Reference Guide
rsaquo NEA FastAttachreg ndash Secure information exchange that is cost-effective and reliable To learn more visit National Electronic Attachment (NEA) FastAttach at nea-fastcom or call 8007825150 Discounts are available for Cigna Dental network dentists through the Cigna Network Rewards Programreg (refer to page 13 of this guide for more program details)
Electronic submission eliminates the need for duplicate x-rays or self-addressed stamped envelopes
Visit CignaforHCPcom gt Resources gt Payment Guidelines gt Electronic Claim Submission to learn more
Cigna Network Rewards visit CignaforHCPcom gt Resources gt Dental Resources gt Cigna Network Rewards Program
Save time ndash submit your claims electronically
To learn more about electronic claims submission with Cigna log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Not registered to use the website Go to CignaforHCPcom and click ldquoRegister Nowrdquo
Note For claims with no service dates the 276277 transaction will default to the process date
For questions about claims submitted through your clearinghouse contact the clearinghouse directly For questions about Cigna claim processing call Customer Service at 800Cigna24 (8002446224)
Claim inquiry and follow-up
You can inquire about the status of your claims through several methods EDI transaction 276277 the Cigna for Health Care Professionals website at CignaforHCPcom our interactive voice response system or by speaking with a customer service representative
NPI needed for EDI transactions
When you submit claims or encounters electronically or transmit other electronic transactions you must include your NPI Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008 Also the TIN (Employee Identification Number or Social Security number) of the billing provider must be submitted on electronic claims
Benefits of submitting claims to Cigna electronically
rsaquo Quicker claims submission including DHMO encounters
rsaquo Receive payments faster
rsaquo Improve claims accuracy ndash reduces errors and missing data
rsaquo Track claims received electronically which are automatically archived before processing
rsaquo Save time on resubmissions ndash incomplete or invalid claims can be reviewed and corrected online
rsaquo View track and monitor claim status reports
rsaquo Send primary and secondary coordination of benefits (COB) claims quickly reduce paperwork and eliminate printing and mailing expenses
How to submit claims electronically
EDI vendors ndash To connect electronically with an EDI vendor you only need a computer and a printer Costs vary by practice management system vendor or clearinghouse Some practice management software companies may offer free claim submissions for the first three to six months Cigna is directly connected to three vendors who provide web claim data entry for dental offices that have internet access but no office management system Visit CignacomEDIvendors to learn more
Using Payer ID 62308 you can electronically submit all claims and encounters at the same time ndash indemnity DPPO and DHMO This includes general dentistry and specialty encounters Both primary and secondary COB claims should be submitted to Cigna electronically
Submit X-rays electronically
You can submit X-rays and other attachments electronically through any of the following options
rsaquo Standard EDI 275 attachment transactions through your clearinghouse
rsaquo DentalXChange Attachment Service available free of charge for DentalXChange Claim Connecttrade subscribers
Cigna Dental Health Provider Solutions (continued)
7PPO | Dental Office Reference Guide
Benefits of enrolling in EFT
rsaquo Eliminate paper check mail delivery and handling
rsaquo Access funds on the same day of the deposit
rsaquo View a separate remittance report online for each deposit which shows the
mdash Deposit transaction
mdash Details about the claims processed
mdash Payments included in that fund transfer
rsaquo Easily reconcile payments using a single remittance tracking number
mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you
mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA
mdash Number located on the right side of the first page of your online claim payment report
Payment bulking options
Choose between two options to receive your payments
rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office
rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office
mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor
mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI
EFT enrollment guidelines
rsaquo For savings account deposits verify that your bank will support EFT
rsaquo The enrollment process typically takes two to four weeks
rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN
Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions
Electronic funds transfer and electronic remittance advice
Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear
What is EFT
rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement
rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll
rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule
Cigna Dental Health Provider Solutions (continued)
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
7PPO | Dental Office Reference Guide
Benefits of enrolling in EFT
rsaquo Eliminate paper check mail delivery and handling
rsaquo Access funds on the same day of the deposit
rsaquo View a separate remittance report online for each deposit which shows the
mdash Deposit transaction
mdash Details about the claims processed
mdash Payments included in that fund transfer
rsaquo Easily reconcile payments using a single remittance tracking number
mdash Ask your bank to provide the payment-related information from field 3 of record 7 on the EFT report they send to you
mdash ldquoReference Identification Fieldrdquo (or TRN02) on your ERA
mdash Number located on the right side of the first page of your online claim payment report
Payment bulking options
Choose between two options to receive your payments
rsaquo By dental office ndash All of your claims will be grouped into a single payment based on your dental office
rsaquo By National Provider Identifier (NPI) ndash All of your claims will be grouped into a single payment for each ldquoBilling Providerrdquo NPI from the submitted claim for each dental office
mdash The ERA or payment report will be bulked by a Taxpayer Identification Number (TIN) or NPI depending on your payment bulking preference with your EDI vendor
mdash You can elect a separate bank account for each ldquoBilling Providerrdquo NPI
EFT enrollment guidelines
rsaquo For savings account deposits verify that your bank will support EFT
rsaquo The enrollment process typically takes two to four weeks
rsaquo If you use more than one Taxpayer Identification Number (TIN) you must complete a separate enrollment for each TIN
Beginning in May 2005 the National Plan and Provider Enumeration System (NPPES) an entity established by the federal government began issuing NPIs to health care providers who apply and qualify for them For general information about the NPI and the NPI application process visit wwwcmshhsgovappsnpinpiviewletasp at the Centers for Medicare amp Medicaid Services web page To apply online for an NPI visit wwwnppescmshhsgovNPPESWelcomedo
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association (ADA) has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your fee schedule will be considered covered services in accordance with each memberrsquos dental plan We expect you to use the current CDT codes for claims transactions
Electronic funds transfer and electronic remittance advice
Improve your office workflow and productivity and shorten the payment cycle by enrolling in electronic funds transfer (EFT) When used together EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow ndash no more waiting for paper checks to clear
What is EFT
rsaquo Electronic funds transfer (EFT) is Cignarsquos standard payment method for provider reimbursement
rsaquo EFT is a secure direct deposit into your bank account It is a proven method for securely receiving your payments To take advantage of the benefits of EFT you must enroll
rsaquo A calendar of payment dates can be accessed by visiting CignaforHCPcom gt Resources gt Payment Guidelines gt Direct Deposit Payment Schedule
Cigna Dental Health Provider Solutions (continued)
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
8PPO | Dental Office Reference Guide
Tips for enrolling in ERA and EFT
rsaquo Make sure that your payment bulking preferences are the same for ERA and EFT
rsaquo If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI) you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI
rsaquo To learn more log in to CignaforHCPcom gt Resources gt eCourses or call 800Cigna24 (8002446224)
Zelis Payments
Cigna has partnered with Zelis Paymentscopy an electronic payments solutions company through which you can improve your automated claim payment experience and ease of doing business with Cigna This service supports both Cigna DPPO and Cigna Dental Carereg provider payments There are fees associated with this service
For details on how to enroll associated fees or more information on the program please call Zelis Payments directly Monday through Friday between 900 am and 700 pm ET at 18778288770 or send an email to wwwzelispaymentscom
Online reports
You will access all of your dental reports at CignaforHCPcom Either click on Payments (Claim Payment Reports) or Reports (Office Management and Financial Reports) Claim payment reports office management reports and financial reports are all available whether enrolled in EFT or not
rsaquo To have your payments bulked or grouped based on your billing NPI and dental office from the submitted claim visit CignaforHCPcom gt Working with Cigna gt Manage EFT Settings and update your payment bulking preferences
rsaquo The method you choose to bulk your EFT payments (by TIN or NPI) should match how you bulk your ERAs Contact your EDI vendor for changes to your ERAs
rsaquo If your TIN NPI billing address or bank account changes you must submit a change request by logging in to CignaforHCPcom gt Working with Cigna gt Manage EFT Settings
rsaquo If your TIN billing address or bank account changes you must submit a change request by logging in to the Cigna for Health Care Professionals website (CignaforHCPcom) gt Working with Cigna gt Manage EFT Settings
Enroll in EFT ndash two options
rsaquo Enroll in EFT and manage EFT accounts directly with Cigna by logging in to CignaforHCPcom gt Working with Cigna gt Enroll in Electronic Funds Transfer (EFT) Options
rsaquo Enroll in EFT with multiple payers including Cigna using the Council for Affordable Quality Health Care (CAQH) website httpssolutionsCAQHorg
What is ERA
ERA or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction is the HIPAA-compliant detailed explanation of how a submitted health care claim was processed
Benefits of enrolling in ERA
ERAs can be automatically loaded into your accounts receivable system which can help
rsaquo Reduce costs and save time
rsaquo Reduce posting errors
rsaquo Shorten the payment cycle
Enroll for ERA
rsaquo Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA
ERA enrollment guidelines
rsaquo Provide enrollment information as instructed by your EDI vendor
rsaquo If you use more than one TIN complete a separate enrollment for each TIN
rsaquo Your EDI vendor will send the completed enrollment information to Cigna for processing
rsaquo Cigna will finalize your registration within 10 business days of receiving it
rsaquo You may begin receiving ERAs on your next payment cycle
Cigna Dental Health Provider Solutions (continued)
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
9PPO | Dental Office Reference Guide
Cultural competency training and resources
Cultural competency training and resources are available to dental health care providers at no additional cost on Cignacom Resources include articles training videos a health equity brochure and a powerful public service announcement on the importance of language interpreters in health care Visit Cignacom gt Health Care Professionals gt Resources for Health Care Professionals gt Health amp Wellness Programs gt Cultural Competency Training and Resources
rsaquo The billing NPI submitted on your claim(s) is included in the Provider Summary (TS3) field to help you easily reconcile your payment
Interactive voice response (IVR) ndash Speech recognition technology
Cignarsquos enhanced speech recognition technology gives you and your staff instant access to information for customers with DHMO DPPO and indemnity plans ndash all by using a touch-tone phone With IVR you are able to request and acquire eligibility information on multiple customers during the same call and have that information provided to you over the phone or via fax
IVR features
Important Before you call please be prepared to enter the patientrsquos Cigna ID the patientrsquos date of birth and the dentistrsquos TIN
rsaquo Call Customer Service at 800Cigna24 (8002446224)
rsaquo Identify yourself as a ldquohealth care professionalrdquo
rsaquo Enter your tax ID number and then you will be asked if you are calling about claims eligibility covered services approvals network participation credentialing or contracting or if you received a letter in the mail
rsaquo State what you are calling about then follow the voice prompts
Cigna Dental Health Provider Solutions (continued)
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
10PPO | Dental Office Reference Guide
Definitions
Alternate Benefit Coverage
Coverage applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than a service proposed or performed by the treating dentist In these instances the patient and the dentist may select a more costly alternative but recognize that the Dental Plan reimbursement may be reduced
Alternate Member Identifier (AMI)
A unique Cigna system-generated number assigned to our dental subscribers to help protect their privacy and personal health information (PHI) assist in preventing identity theft and to comply with certain laws restricting the use of Social Security Numbers (SSNs)
Cigna Network Rewards Programreg
A program of discounts on various products and services offered to Network Dentists through various independent vendors
CignaPlus Savings A program that provides Members access to your Contract Fees which are always paid in full by the Members Members in these Plans may not be charged more than your Contract Fees and should carry an ID card with the Cigna logo and statement indicating that the program or plan is ldquonot insurancerdquo
Coinsurance The payment a Member is required to make to a Network Dentist for Covered Services listed under the Memberrsquos Dental Plan This payment is calculated as a percentage of the Contract Fee for such services
Contract Fee The fees set forth in the applicable Fee Schedule that are considered payment in full for all services to Members
Covered Service A dental service for which a Member is entitled to receive coverage or access to Contract Fees under the Memberrsquos Dental Plan
Date of Service Cigna Plans are based on the date of completion (seating and delivery) in the calculation of eligible coverage
Deductible A payment that a Member is required to make to a Network Dentist in accordance with the Memberrsquos Dental Plan prior to the initiation of Plan Payments This payment is a fixed dollar amount
Dental Emergency A dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that his or her condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection
Dental Plan A Certificate of Coverage Summary Plan Description or other document or agreement that specifies the dental services to be provided or reimbursed for the benefit of a Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees to employers who administer their own Dental Plans third party administrators and other insurers Dental Members in these programs should carry an identification (ID) card with the Cigna logo and a toll-free number for eligibility and claims verification and information
Dependents Typically a subscriberrsquos spouse (or domestic partner) and unmarried minor children as defined in the Grouprsquos Dental Plan
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
11PPO | Dental Office Reference Guide
Exclusions and Limitations
Services or expenses that are not covered under the Memberrsquos Dental Plan or for which certain restrictions apply
Fee Schedule The schedule established by Cigna that sets forth commonly covered procedures and the payment that the Network Dentist has agreed to accept as payment in full for providing a Covered Service to any Member Different Fee Schedules may apply to different Network Dental Offices based upon the geographical locations of the Network Dental Offices
Maximum A fixed annual or lifetime maximum dollar amount of coverage up to which the Dental Plan will provide reimbursement
Member Any individual who is eligible and entitled to receive Covered Services
National Provider Identifier (NPI)
A unique identification number for use in standard health care electronic transactions
Network Dentist Agreement
The Cigna Network Dentist Agreement that you executed including all attachments and any amendments thereto including this Dental Office Reference Guide as it may be changed from time to time
Network Dental Office The dental office(s) of the Network Dentist listed on the Network Dentistrsquos application for participation and any others approved in writing by Cigna for inclusion under the terms of the Cigna Network Dentist Agreement
Network Dentist A dentist who has entered into a Network Dentist Agreement with Cigna
Payer The person or entity obligated to a Member to provide reimbursement for Covered Services under the Memberrsquos Dental Plan which Cigna has agreed may access your services under this Agreement
Plan Payment The portion of your compensation paid by the Dental Plan
Pre-Treatment Review An optional service provided by Cigna to review treatment plans to determine whether coverage is payable based on a Dental Plan
Quality Management Program
The review processes established and implemented by Cigna or its designees relating to the quality of services rendered to Members which may include onsite assessments of the Network Dental Office
Usual Fee The Network Dentistrsquos usual charge for a given procedure
Waiting Period The amount of time a Member must be continuously enrolled in the Dental Plan before certain covered services are payable When included Waiting Period requirements may differ based on the Memberrsquos Dental Plan andor state regulations
Definitions (continued)
Certain terms are defined in this Dental Office Reference Guide which are also defined in your Cigna PPO Agreement To the extent that there may be any conflict or inconsistency in the definition of any such terms the definitions contained in this Dental Office Reference Guide shall apply
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
12PPO | Dental Office Reference Guide
As a dentist in a Cigna Network you can expect new patients from a number of different programs They are all based on providing Members with a discounted fee-for-service benefit All of the Plans we offer will help you build your patient base by leveraging the discounts that you have agreed to accept under your Network Dentist Agreement The common theme across the programs is that all of your compensation is based on your Cigna Fee Schedule This may include but is not limited to the segmentation or tiering of the Dental Network It is important that your office verify patient eligibility and benefits specific to their plan in your office prior to delivering dental care Cigna makes no representations or guarantees to dentist regarding the number andor identity of covered persons or prospective income to be derived by dentist for providing dental services to Members In addition Cigna reserves the right to direct Members to selected dentists andor influence a Memberrsquos choice of dentist
PPO dental plans
PPO dental plans Dental Plans that provide coverage to Members whether they receive services from a Network Dentist or an out-of-network dentist Typically the Plans contain financial incentives for Members who choose to receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Exclusive provider organization (EPO) dental plans
EPO dental plans Dental Plans that provide a coverage to Members only when they receive services from a Network Dentist Members are responsible for paying a portion of the fees on your Fee Schedule which they typically pay in the form of Deductible and Coinsurance payments There is no balance billing for any services provided to Members in these Plans
Optional programs
The choice is yours
Your participation in Cigna programs can be as broad or as narrow as you wish Again we want to be a partner who assists you in building a patient base that is consistent with your business goals The following options can be added to or removed from your Cigna Plan participation by simply calling the Cigna Dental Provider Service Unit at 8002446224 (800Cigna24) or by using the secure Cigna for Health Care Professionals website
CignaPlus Savingsreg is a discount dental plan that requires plan participants to pay the officersquos contracted fee in full directly to the network dentist This is not insurance so there are no claim forms to file You will be able to identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and the following phrases ldquoThis is not insurancerdquo and ldquoThe card holder is directly responsible for all payment to the Dentist or Providerrdquo
The Cigna dental Shared Administration program is available to plan participants through Taft Hartley Funds and their contracted Third-Party Administrators (TPAs) It operates the same as a standard Cigna PPO plan except that all claims are submitted to and paid by the TPA and not by Cigna You can identify plan participants when they present their ID cards prior to receiving service The ID card will be imprinted with the Cigna logo and contain a toll-free telephone number that you may call to check eligibility for benefits and information on where to send the claim for payment Plan participants are responsible for paying deductibles and coinsurance There is no balance billing
In no case does your nonparticipation in any of these options jeopardize your participation in the Cigna PPO Network
For more information on the website log in to CignaforHCPcom
Plan descriptions
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
13PPO | Dental Office Reference Guide
The Cigna Network Rewards Program ndash The program that gives you earning power
Your participation in our Dental Network means more than just treating patients ndash it gives you the opportunity to take advantage of lower costs on key products and services Membership in the Cigna Network Rewards Program is automatic and free to dentists who participate in the Cigna networks
This program includes a wide array of vendors that offer discounts to you ndash just for being a Cigna Network Dentist Discounts are available on products and services in the following categories Office and dental suppliesequipment practice management tools dental labs education website development and services consulting and legal services and health and wellness
To view the entire list of Cigna Network Rewards Program vendors along with the discounted products and services available to you log in to the Cigna for Health Care Professionals website at CignaforHCPcom gt Resources gt Dental Resources gt Cigna Dental Network Rewards Program
Cigna Network Rewards Program
THE POWER TO SUCCEED
rsaquo New patients
rsaquo Expanding markets
rsaquo Competitive compensation
rsaquo A responsive professional business ally
rsaquo Affiliation with an industry leader
rsaquo Tools to help your practice thrive
Did you know that millions of Americans have private dental insurance and that the number is expected to continue to climb Thatrsquos a significant market With our experience reputation and national presence we expect to continue to claim a substantial share of that market At Cigna we want to share that success with you
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
14PPO | Dental Office Reference Guide
We take pride in finding dental health professionals who share our commitment to professionalism dedication and consistency of service Your selection as a Preferred Dental Health Professional means our Members can trust that their selection of a Network Dentist will never result in a reduction or limitation of care and attention Thank you for allowing us to keep this important promise to our valued clients and your patients
Cigna PPO and EPO members
rsaquo Must be able to receive an appointment for initial routine and hygiene care within four weeks of calling your office in accordance with your standard office practice
rsaquo Must be scheduled for regular recall visits in the same manner as your other patients
rsaquo Must have emergencies addressed within 24 hours (or less if medically necessary)
Connecticut ndash Routine care appointments should be offered within 10 days for general dentists and 15 days for specialists from the date of request Urgent care appointments must be offered within 48 hours of the time of request
Vermont ndash Members must be able to receive an appointment for routine care within two weeks Additionally routine lab and X-ray appointments must be available within 30 days and routine preventive care appointments must be available within 90 days Emergency care appointments must be addressed immediately
Administrative policies and guidelinesAppointment wait time
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
15PPO | Dental Office Reference Guide
Benefits and eligibility verification process
We recommend that your office staff verify Member eligibility and benefits specific to their plan in your office each time services are rendered to confirm that the Member is eligible for Dental Plan coverage For example some Dental Plans include Waiting Periods that must be satisfied before benefits for certain services are payable Please note that benefits and application of those benefits may vary by patient The method you use for verification of eligibility and benefits may vary based on the materials the Member brings to your office and the plan they participate in Eligibility can be confirmed by using the
rsaquo Online tool via the secure Cigna for Health Care Professionals website at CignaforHCPcom to verify eligibility for up to 10 Members at one time
rsaquo Memberrsquos ID card (if available)
rsaquo Memberrsquos certificate booklet (if available)
rsaquo Memberrsquos claim form
If the Member does not have these items you may call Customer Service at 8002446224 (800Cigna24) and a representative will work with your office staff to identify the Memberrsquos Plan
CignaPlus Savings verification process ndash Follow the instructions on the Memberrsquos ID card
Dental Shared Administration verification process ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine Memberrsquos eligibility coverage levels and claim status Members in these programs should carry an ID card with the Cigna logo and a toll-free number for eligibility and claims verification and information
The Fee Schedule
The Fee Schedule lists the majority of dental services commonly covered by the various Cigna PPO and EPO plans Some dental procedures when they are performed as part of another dental service are not covered as a separate benefit Please keep in mind the Cigna PPO and EPO plans vary by Group and that each Memberrsquos coverage reflects the Dental Plan design selected by his or her plan sponsor
Compensation
Your compensation from the Dental Plan for all services will be based upon your Contract Fee (or your Usual Fee in the rare instance that it may be lower for a given procedure) The Dental Plan payment will be calculated after Deductibles Coinsurance alternate benefits and other Dental Plan limitations have been applied
Compensation from the Dental Plan may be subject to IRS withholding provisions regarding the matching of taxpayer identification and name For Covered Services Cigna or the appropriate Payer will pay the Contract Fee listed in the applicable Fee Schedule after Deductibles Coinsurance Dental Plan limitations and alternate benefits have been applied
The Dental Plan may deny payment for a Covered Service if it is determined that such Covered Service did not meet the criteria for coverage When this occurs the Network Dentist must not collect any charges or fees for the Covered Service from the Member unless he or she obtained prior consent from the Member to perform the optional services This consent must include an acknowledgement by the Member that he or she is solely responsible for paying the Network Dentistrsquos contracted fees for such services The Member should not be charged for services considered inclusive to another procedure Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Prohibited charges include but are not limited to office overhead expenses lab fees (for example dentures crowns and bridges) infection control costs charges for completion of claim forms and charges for submission of information to the Dental Plan
For any overpayments made by the Payer to a Network Dentist the Dental Plan may withhold other claim payments otherwise due When this happens the Network Dentist must not collect charges or fees from the Member for the Covered Service In the event the Network Dentist receives from the Payer or the Member a payment in excess of the amount determined by the Dental Plan to be due the Network Dentist must promptly return the excess amount to the Dental Plan or the Member as the case may be Dentist agrees to refund to Payer or its designee any excess payments made by a Payer to the dentist in the event the dentist
Administrative policies and guidelines (continued)
Billing guidelines
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
16PPO | Dental Office Reference Guide
is overpaid by Payer for any dental services Cigna may at its option deduct any excess payment from other payments due and payable to the dentist
Cigna reserves the right to re-code claims as necessary for proper adjudication Some dental procedures are considered part of other procedures and will not be compensated separately
When preparing a bill charge the Member his or her Coinsurance percentage including their Deductible if it is not yet met Call the number on the Memberrsquos ID card to verify the amount
All Member Coinsurance must be calculated based upon the applicable Contract Fee Balance billing beyond the Contract Fee is not permitted for any service provided to the Member The Contract Fee applies to non-Covered Services and to Covered Services even after the Member has reached his or her annual maximum or exceeded frequency limitations missing tooth limitations or other similar limitations of the Dental Plan
CignaPlus Savings
CignaPlus Savingsreg and Dental Network Access Plans are Dental Discount Plans Under these and similar Plans Members will present a card with the Cigna logo and instructions that typically say ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo The card may include logos of other companies as well Cardholders or CignaPlus Savings Members are not covered by insurance CignaPlus Savings Members are entitled to the Cigna PPO Contract Fees for all services which they are required to pay in full directly to the Network Dentist All treatment and payment arrangements are between the Network Dentist and the Member
Dental Shared Administration
A program offered by Cigna that provides access to your Contract Fees by employers who administer their own Dental Plans third party administrators and employers who contract with other insurers Members in these programs should carry an ID card with the Cigna logo and a toll-free telephone number for eligibility and claims verification and information Dental Plans offered
pursuant to this program may include PPO and EPO Plans and will typically require Members to pay for a portion of the fees on your Fee Schedule There is no balance billing for any services provided to Members in these Plans
Treatment plans policy
The use of signed treatment plans for member payment is acceptable under some circumstances however not acceptable for others The signed treatment plan should not be intended to charge the member additional fees for services including but not limited to the following
rsaquo Inclusive services
rsaquo In-housesame day crowns (CADCAM eg CERECreg or E4Dreg technology)
rsaquo Materials for crowns above and beyond crown ADA code submitted on the claim form
rsaquo Shading
rsaquo Upgraded materials andor brand name restorations
rsaquo Porcelain margins
rsaquo Lab fees
rsaquo Laser treatment
rsaquo Use of dental equipment and tools
rsaquo Temporary Services
Below are acceptable additional charges with a signed treatment plan
rsaquo Clear or decorative brackets for orthodontics
rsaquo Clear aligners (eg Invisalignreg Claritytrade ClearCorrecttrade)
rsaquo External rush lab fee requested by patient (external lab bill required)
Non-covered services
Covered Services not paid by Cigna
Covered services that are deniednot paid by Cigna contractual provisions including but not limited to frequency or age limitations a benefit maximum exceeded a contractual provision that would result in a denial of coverage or a patient does not meet the
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Note Federal Government employee plans are exempt from state regulations for non-covered services
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
17PPO | Dental Office Reference Guide
prevent dental plans from requiring participating dentists to charge their contracted rate for services not covered by the plan The requirements of each state law may vary and all claims will be processed according to the applicable state requirements Please refer to the Cigna for Health Care Professionals website at CignaforHCPcom for the current list of impacted states
If you are a contracted PPO dentist in one of these states you are not required to charge your contracted rate for services not covered by your patientrsquos dental plan The member is responsible for payment directly to you for non-covered services at your usual fee
All contracted PPO dentists that are not in states with specific non-covered services legislation are required to charge the amount listed on their fee schedule Procedures not listed on your fee schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less
Although New York has not enacted specific legislation regarding discounts for non-covered services pursuant to a business decision Cigna will no longer require the acceptance of contracted fees for services that are not covered
Alternate benefit provision
If the Dental Plan should allow coverage for an alternate benefit in lieu of the procedure(s) performed you may bill the Member the balance up to the Contract Fee amount for the services actually performed The Alternate Benefit Provision may be applied when a dental condition can be treated by a professionally acceptable procedure that is less costly than the service actually performed by the treating dentist In this instance the Dental Plan will provide coverage for the less costly service The Member and the Network Dentist may choose to proceed with the more costly alternative but need to recognize that the Dental Plan reimbursement may be reduced An example of this might be when a removable partial denture can restore missing teeth satisfactorily and the Network Dentist submits a claim for a fixed bridge The Dental Plan will reimburse based on the Contract Fee for the partial denture the difference between this amount and the Contract Fee amount for the fixed bridgework is entirely the Memberrsquos responsibility We recommend but do not require the use of pretreatment estimates
criteria to be covered may still be considered to be a covered service under a statersquos statutory definition and therefore subject to the terms of your agreement The member is responsible for any amounts not paid by Cigna based on your contract fees You may not charge the patient your usual fees
Covered Services not listed in your Fee Schedule
Covered Services not listed on your Fee Schedule will be compensated at 20 off your usual fee or the maximum fee allowed by Cigna based on fees submitted by dentists in the geographic area whichever is less Charges other than those allowed for professional services rendered by the Network Dentist are not permitted Since the American Dental Association may periodically change CDT codes this 20 discount will never apply when there is a comparable code already listed on the schedule
Services not covered listed in Memberrsquos Certificate booklet
For services listed in the ldquoServices not Coveredrdquo section of the Memberrsquos certificate booklet but that are listed on your Fee Schedule the Member is responsible for payment directly to you at your Contract Fee except for states with non-covered services legislation as explained hereinafter The Network Dentist may not charge Members in excess of the Contract Fee for non-Covered Services included on the contracted fee schedule
If a customer has elected to receive a non-covered service or an upgraded service that would not be considered part of a covered service andor not typically covered under their current plan (eg use of orthodontic aligners such as clear braces as opposed to traditional braces services completed solely for cosmetic reasons rush lab turnaround times etc) and the member has signed a consent form release or Treatment Plan that accepts responsibility for that non-covered or upgraded service the Company will not interfere with that extra-contractual arrangement and the Member shall be responsible for the payment of that non-coveredupgraded service
State-specific legislation for non-covered services
Individual states have enacted legislation that impacts Cigna Dental PPO dentist contracts These state laws
Administrative policies and guidelines (continued)
Billing guidelines (continued)
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
18PPO | Dental Office Reference Guide
in instances such as this so that both the Network Dentist and the Member are aware of the Memberrsquos financial responsibility prior to treatment Please utilize the pretreatment review process in order to simplify these situations
National provider identifier
The national provider identifier (NPI) is a unique identification number for use in standard health care transactions It is a number issued to health care providers and covered entities that transmit standard HIPAA electronic transactions (eg electronic claims and claim status inquiries) As of May 2005 the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care providers that apply and qualify
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and was required to be used by health plans and health care electronic data interchange (EDI) vendors in HIPAA standard electronic transactions by May 23 2007
In addition the NPI
rsaquo Replaces other identifiers previously used by health care providers and assigned by payers (eg UPIN MedicareMedicaid numbers)
rsaquo Establishes a national standard and unique identifier for all health care providers
rsaquo Helps simplify health care system administration and encourage the electronic transmission of health care information
Cigna is capable of accepting the NPI on standard HIPAA transactions as outlined in the Claim Submission section of this reference guide This approach should not be confused with any guidance specific to Medicare claims requirements
Administrative policies and guidelines (continued)
Billing guidelines (continued)
Use of Social Security numbers
In response to the current legislative and cultural environment surrounding the use of Social Security numbers (SSN) for all nonessential purposes Cigna removed SSNs from Cigna ID cards and correspondence
SSNs were replaced with an alphanumeric Alternate Member Identifier (AMI) In order to ensure that both service and access to care are unaffected by these changes you may simply need to ask for the employeersquos SSN or AMI when needed The collection of SSNs are still permitted for purposes of benefit plan administration and the continued use of SSNs extends to dental health professionals However we will submit the memberrsquos AMI to you on reports Explanation of Benefits letters and other documents You are also allowed under the laws to continue to submit SSNs or AMIs for the purposes of verifying eligibility and coverage authorization and claims submission Please contact Customer Service at 800Cigna24 (8002446224) Monday through Friday between 800 am and 500 pm if you have any questions about this change For questions about member eligibility please call Customer Service at 800Cigna24 (8002446224)
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
19PPO | Dental Office Reference Guide
Who should submit claims
The Network Dentist is responsible for submitting claims for all services rendered to Members including services that may not be covered This information is necessary to provide the member a complete explanation of all benefits This is true for all Dental Plans except the Dental Discount Plan such as CignaPlus Savingsreg which are not insurance programs and do not have claims submission requirements
Cigna may seek additional clinical dental information including radiographs periodontal pocket depth charting progress notes and other documents necessary to review the claim A list of the more frequently submitted procedures that require claim attachments appears on page 22
When to submit claims
Claims should only be submitted for completed services eg insertion dates are required for crowns bridges dentures or final fill of root canals Submitting procedures on preparation dates will cause related services submitted with the same date of service to be denied as inclusive (ie D2950) If a CADCAM system was used for same day placement you should note this on the claim form
Claims should be submitted to Cigna as soon as possible after completion of the dental procedure Claims submitted more than 180 days from the completion date may be denied for payment as standard
The Network Dentist may not charge the Member for the portion of the fee which would have been paid by the Dental Plan for Covered Services had the claim been submitted in a timely manner
How to submit a claim
You must include the following information when submitting a claim The Member name Member ID number treating dentist name tax ID number SSN address where services were rendered date of service procedure codes procedure descriptions your Usual and Customary Fee the amount charged tooth number surfaces quadrants location or arch All charges should
be submitted to the Dental Plan using one of the following methods
rsaquo Electronically through a clearinghouse that provides electronic interface with third party Payers
rsaquo Via standard ADA Dental Claims Forms
rsaquo Via a Dental Plan Claim Form
rsaquo Forms that may be required by any state regulations
Paper claims should be submitted to the following address
Cigna PO Box 188037 Chattanooga TN 37422-8037
CignaPlus Savings ndash If the Memberrsquos ID card contains the Cigna logo and wording similar to ldquoThe cardholder is directly responsible for payment to the dentist or dental health professionalrdquo then heshe is directly responsible for the payment of full Contract Fees for all services You should collect your Contract Fee from the Member and there is no need to submit a claim form For questions call the toll-free number on the Memberrsquos ID card
Dental Shared Administration ndash You will contact the Payeradministrator directly at the number listed on the back of the Memberrsquos ID card to determine where to submit your claims for payment
Important notice Fee submission
When filing your PPO claims please submit your Usual Fees Submitting your Usual Fees will help to ensure that we capture accurate prevailing charge data for your area which is used in the development and updating of Fee Schedules
Electronic claims (837) and attachments
Electronic claim submissions and attachments are processed through a third-party vendor Please contact your local vendor directly if your office is not already participating in the electronic claim submission process and is interested in doing so Please see additional information in the section for Cigna Dental Health Professional Solutions
Administrative policies and guidelines (continued)
Claims submission
Subject to State and Federal regulations
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
20PPO | Dental Office Reference Guide
Electronic remittance advice (835)
rsaquo In most instances the ldquoBilling Providerrdquo (claim payee) NPI will be included on the 835 If more than one claim is included in a single 835 The NPI will be included in the 835 only if all NPIs from the submitted claims are equal The NPI for the ldquoRendering Providerrdquo will be included in the 835 if the ldquoRendering Providerrdquo NPI was submitted on the claim
Real-time request transactions (270 276 278)
rsaquo All real-time request transactions will be accepted with NPI Cigna will return the NPI when it was submitted on the inquiry Contact your EDI vendor for details regarding the submission of NPI on these transactions
rsaquo When a NPI is received on a 276 claim status inquiry the claims that submitted the same NPI will be returned on the 277 claim status response
rsaquo When a NPI is received on a 270 eligibility and benefit inquiry Cigna will return your network participation status for the patient in the 271 eligibility and benefit response
Additional information is available on CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cignagt National Provider Identifier (NPI)
ADA codes and electronic transactions
Federal HIPAA regulations require use of only the latest Code on Dental Procedures and Nomenclature (CDT) codes for electronic claims transactions Since the American Dental Association has announced that it plans to revise the CDT code every year it is important to understand that administration may change slightly from time to time However procedure codes and descriptions that are comparable to those on your Fee Schedule will be considered Covered Services in accordance with each memberrsquos Dental Plan We expect you to use the current CDT codes for claims transactions
rsaquo Required data elements such as the ldquoBilling Providerrdquo Taxpayer Identification Number (TIN) ldquoRendering Providerrdquo name and rdquoBilling Providerrdquo address must always be included on professional institutional and dental claims Inclusion of this information does not change because of NPI implementation
rsaquo As with any change to your billing process if you plan to change the way you submit claims to Cigna please contact Customer Service at 800Cigna24 (8002446224) to update your information One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the ldquolowest enumeratedrdquo subpart health care providers
rsaquo When using the NPI to identify the ldquoBilling Providerrdquo the TIN must be submitted as a secondary provider identifier This TIN is the number used on the IRS Form 1099 which is either the employer identification number (EIN) for organizations or the Social Security number (SSN) for individuals Both numbers should not be included concurrently Other identifiers such as the Medicare provider number are considered ldquolegacyrdquo identifiers and should not be included
rsaquo Submission of the ldquoBilling Providerrdquo TIN on the electronic claim is a HIPAA requirement The National EDI Transaction Set Implementation Guide specifically states the following
ndash If lsquocode XX ndash NPIrsquo is used then either the Employerrsquos Identification Number or the Social Security number of the provider must be carried in the REF in this loop The number sent is the one which is used on the 1099
rsaquo Under HIPAA 5010 standards ldquoPay to Providerrdquo information is limited to an alternate address only No additional identifiers neither TIN nor NPI are permitted The ldquoPay to Providerrdquo address is only needed if it is different than that of the ldquoBilling Providerrdquo
Cigna will reject electronic claims received without a NPI unless the submitter is ineligible to receive an NPI If you are not eligible to receive an NPI notify Cigna by updating your demographics
Administrative policies and guidelines (continued)
Claims submission (continued)
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
21PPO | Dental Office Reference Guide
is a change in the dental health professionalrsquos Contracted Fee Schedule the Member will only be responsible for the charges agreed to on the initial treatment plan However if the treatment plan changes or there is an interruption in the patientrsquos coverage or treatment then a later change in the Fee Schedule may apply
The Member payment for the entire orthodontic case will be based upon the status of the dental health professional on the date of the visit for initial banding If the dental health professional was not a participating Network Dentist on the date of the visit for initial banding the patient will be responsible for the charges agreed to in the initial treatment plan
Surgical cases
For orthodontic procedures that have a surgical component please submit to the memberrsquos medical policy
Cigna debit card
The Cigna debit card should be used only for ldquomedical carerdquo expenses as defined in Internal Revenue Code section 213(d) Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their flexible spending account (FSA) andor health reimbursement account (HRA) When a patient presents a Cigna debit card the card should not be used for non-eligible medical care expenses such as cosmetic procedures When Cigna patients use their debit card for their in-network health care provider visits substantiating these claims helps to improve their experience and speed up how quickly you get paid by us If the transactions are not eligible per IRS regulation the patient should be asked to provide a separate additional form of payment Additional information about eligible transactions can be found at Cignacomexpenses or httpwwwiRSgovpublicationsp969indexhtml You can also call Cigna Customer Service at 800Cigna24 (8002446224)
Coordination of Benefits
If you are aware that the Member has dental coverage through more than one plan please submit claims to the primary carrier first and then submit the Explanation of Benefits from the primary carrier with your Claim Form to the secondary carrier When Cigna is primary the benefit will be paid without regard to payments of the secondary carrier Coordination of Benefits described in the Dental Plan certificate booklet will apply when Cigna is secondary
Orthodontic claims
Claims for orthodontic treatment should include the respective CDT code along with a description of the treatment the initial banding date the length of treatment and the total treatment cost (including retention) based on your Usual and Customary Fees In order to save your office time and administrative costs please do not submit recurring monthlyquarterly claims for the same treatment plan These claims are not required and will not be processed Our systems will automatically process the orthodontic claim on a recurring basis until coverage is exhausted
Invisalignreg cosmetic appliances
Additional costs associated with optionalelective materials of a cosmetic nature (eg clear ceramic clarity and decorative brackets) may be charged to the patient If the patient opts for any of these he or she will be responsible for the difference between Cignarsquos allowances for standard treatment and the dentistrsquos regular fees for these optional elective materials These fees for these materials along with their description should be submitted on the claim form
Orthodontics in progress Change in Fee Schedule or dental health professional status
The Member payment for an entire orthodontic case including retention will be based upon the Fee Schedule in effect on the date of the visit for initial banding If there
Administrative policies and guidelines (continued)
Claims submission (continued)
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
22PPO | Dental Office Reference Guide
1 Restorative claims Multiple anterior crowns or multiple onlays
rsaquo Current periapical radiographs and clinical rationale demonstrating need if not evident
(Submit on delivery date not preparation date)
2 Endodontic claims Apexificationinitial visit or hemisection
rsaquo Diagnosis or clinical rationale demonstrating need and current periapical radiographs
3 Periodontal claims Scaling and root planing gingivectomy
gingival flap procedure osseous surgeryrsaquo Current periodontal charting (within 6 months) with
missing teeth noted and diagnosis or clinical rationale demonstrating need
Guided tissue regeneration bone grafting biological modifiers
rsaquo Current periodontal charting with missing teeth noted and current periapical radiographs
Soft tissue grafts rsaquo Description of mucogingival defect tooth number
4 Prosthodontic claims
Removable partial dentures rsaquo Indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis and specific rationale for replacement
Fixed partial dentures rsaquo Full mouth radiographic series indicate if initial placement of missing teeth or replacement of existing prosthesis If replacement of existing prosthesis supply date of prior placement type of prosthesis being replaced and specific rationale for replacement
5 Oral surgery claims
Surgical extractions of 3 or more erupted teeth or removal of impacted teeth or residual roots excluding 3rd molars or 3rd molar extractions for patients under the age of 15
rsaquo Current diagnostic radiographs
Biopsy andor removal of cysts rsaquo Current diagnostic periapical radiographs and pathology report
6 ldquoBy reportrdquo or X999 procedures rsaquo Diagnosis clinical rationale demonstrating need history treatment plan andor radiographs
7 General anesthesia and IV sedation rsaquo Narrative indicating medical necessity
Additional documentation required for reimbursement on designated claims
Please note These are general guidelines for claim submissions Cigna may make requests for additional information on a per-case basis
General recommendations In order to submit a claim you must include the following information The Member name and ID number treating dentistrsquos name license number tax ID number or SSN address where services were rendered date of service procedure code procedure description amount charged and tooth number surfaces quadrants locations or arch
PROCEDURE INDEMNITYPPO GUIDELINE
Administrative policies and guidelines (continued)
Cigna claim attachment guidelines
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
23PPO | Dental Office Reference Guide
Any written communications by the Network Dentist relating to Members the Dental Plans the Payer Cigna or any affiliates or parent company must be reviewed and approved in advance by Cigna This is not intended to prohibit impede or interfere with the individual discussion of treatment options between the Network Dentist and Member
Administrative policies and guidelines (continued)
Communications
Many states are enacting legislation that requires Cigna and other carriers to ensure the accuracy of our provider directories In response to individual state legislation Cigna is now implementing additional procedures to validate the accuracy of information displayed in our directories for contracted dental providers Wersquore also improving our processes to keep this information current If your state enacts directory legislation you must respond to Cignarsquos state-mandated email or postal mail requests for update verification If you do not respond to our outreaches in the respective timeframes your information may be suppressed in our provider directories or your participation may be terminated in accordance with state law
Administrative policies and guidelines (continued)
Directory Accuracy Legislation
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
24PPO | Dental Office Reference Guide
Conditions for participation
The PPO dentist may not restrict his or her participation to particular office locations where heshe practices dentistry The Network Dentist must have the resources staff equipment and facilities to provide Covered Services and must provide these services with the same standard of care skill and diligence used by other dentists in the community In addition the Network Dentist must immediately notify Cigna of the following
rsaquo He or she is charged with indicted or convicted of any felony or crime related to the ability to practice dentistry
rsaquo Becomes the subject of any investigation by any regulatory authority in connection with the practice of dentistry
rsaquo Changes his or her Network Dental Office location
rsaquo Receives a notice of claim or lawsuit related to any alleged professional negligence or malpractice
The dental facility
General office appearance and access
The exterior and common areas of the dental office structure should be well maintained and access to the facility and parking should be adequate Emergency exits should be accessible and well-marked The entire office including treatment areas and restrooms should be clean and uncluttered There should be reasonable accommodations for handicapped and disabled persons All equipment should be in good working order
The Network General Dental Office must have hours of operation of at least two days and 24 hours a week Any exceptions must be approved by the Cigna Credentialing Subcommittee
Sterilization and infection control
Cigna expects all dentists and staff to comply with the Centers for Disease Control and Prevention (CDC) guidelines and Occupational Safety and Health Administration (OSHA) standards and regulations as well as all state and local regulations for the prevention and transmission of communicable diseases Specifically all dentists and clinical staff should
rsaquo Adhere to Universal Precautions based upon the generally accepted principle that all patients must be treated as if they were infected with a bloodborne pathogen
Universal Precautions include
ndash Follow work practice controls such as safe recapping techniques for needles and washing hands
ndash Wear personal protective equipment such as gloves protective gowns or jackets and face shields
ndash Maintain care in the use and disposal of ldquosharpsrdquo including needles scalpel blades and broken glass
ndash Report all exposure incidents according to OSHA guidelines
rsaquo Minimize the chance of cross-contamination by protecting patients and staff from infectious contact with bloodborne pathogens and airborne contaminants by complying with current guidelines for disinfection and sterilization of instruments and equipment that should include the following
ndash Provide a written sterilization plan
ndash Separate the areas where contaminated items are present from the areas where the instruments are clean
ndash Keep the ultrasonic cleaners covered when in use
ndash Sterilize all items used intraorally after each use or properly dispose of disposable instruments
ndash Store sterilized instruments in the same sealed containers bags or cassettes that they were packaged in prior to placing them into the autoclave The packaging preserves the sterile status of the item until it is used on the patient
ndash Use process indicators to demonstrate that the instruments were processed through heat sterilization
Administrative policies and guidelines (continued)
Dental participation guidelines
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
25PPO | Dental Office Reference Guide
Environmental safety
All dentists and staff agree to comply with Cigna OSHA Environmental Protection Agency (EPA) HHS and specific state and local environmental safety regulations pertaining to patients and staff Federal OSHA regulations include the following
rsaquo Maintain an in-office hazardous communication program including
ndash A written hazardous-communication manual
ndash Employee orientation and training in handling and disposing of hazardous waste including mercury developer and fixer ldquosharpsrdquo and disinfectants
ndash Current Material Safety Data Sheets (MSDS) for all materials used in the office
rsaquo Provide the proper protective measures including
ndash Use of masks gloves and protective eyewear
ndash Heavy-duty gloves to be worn while disinfecting treatment areas and handling instruments during the sterilization process
ndash Eyewash equipment according to state regulations
ndash Proper ventilation of chemicals
ndash Laboratory jackets and coats or disposable protective clothing These should be appropriately laundered or disposed of according to state-specific regulations
rsaquo Provide special ldquosharps containersrdquo and dispose of them according to state regulations
rsaquo Have a current hepatitis B (HBV) vaccination for all staff or a written waiver of refusal
rsaquo Adhere to accepted mercury safety recommendations
ndash Use of premeasured amalgam capsules is preferred
ndash Scrap amalgam or bulk mercury should be stored appropriately within a sealed unbreakable container
ndash Mercury spill kit is highly recommended
rsaquo Provide a nitrous oxide recovery system (scavenger unit) if nitrous oxide is used in the office
rsaquo Biological monitoring ldquoSpore Testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore Testing of Sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
rsaquo When items are disinfected in EPA-approved disinfectant solutions they should be soaked following the directions of the manufacturer A log book should be maintained to demonstrate that the solution was active and chemicals changed according to the manufacturerrsquos recommendations
rsaquo Environmental surfaces should be appropriately disinfected and disposable covers properly discarded
rsaquo Provide dental laboratory infection control by rinsing and disinfecting impressions and prosthetic devices sterilizing burs and rag wheels and changing pumice after each use
rsaquo Have a current hepatitis B vaccination for all staff or a written waiver of refusal
rsaquo Compliance with all accepted local state and federal standards with regards to bloodborne pathogens in the treatment of patients and the protection of dental staff
Radiology safety
All dentists and staff agree to comply with Cigna OSHA US Department of Health and Human Services (HHS) and state and local regulatory agencies guidelines for radiology safety for patients and staff Cigna recommends the following radiation safety measures
rsaquo Ensure that radiation protection items used for patients include lead aprons that allow for proper thyroid protection
rsaquo Monitor appropriate personnel to determine acceptable levels of radiation exposure This is a state-specific regulation
rsaquo Provide proper documentation and posting of state-specific radiation safety posters
rsaquo Ensure that radiographic equipment is in good working order well maintained and certified according to specific local state and federal regulations
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
26PPO | Dental Office Reference Guide
dentists and dental specialists using all modalities for producing states of analgesia sedation and general anesthesia
Patient recordkeeping
In keeping with professionally recognized standards of dental practice the patientrsquos dental record should contain key data elements The patientrsquos chart should be well organized legible easily accessible and written in ink or stored in an electronic format that meets industry standards Treatment entries should be signedinitialed and dated by the treating dentist The same type of patient record should be used for all patients and each patient should have his or her own patient record
The following information should be contained in all patient records keeping in mind HIPAA privacy regulations
General patient information
Patient information includes general data such as the patientrsquos name address date of birth SSN or alternate Member ID number home and work phone numbers other insurance information the name and relationship of the person responsible for payment and an emergency contact name and telephone number
Medical history
Medical history is one of the most critical components of the patient record This information is to be taken in its entirety at the time of the patientrsquos first visit to your dental office The dentist is obligated to review the patientrsquos medical history with the patient at this time At subsequent visits the medical history must be updated at regularly scheduled intervals The medical history needs to be signed and updated by the patient or parent or guardian in the case of a minor It must also be signedinitialed and dated by the reviewing dentist Among the medical conditions which should be documented in all medical histories are the presence or absence of the following
rsaquo Allergies (food drug or material including latex)
rsaquo Recent illness or surgery
rsaquo High blood pressure
rsaquo Seizure disorders
rsaquo Diabetes
Medical emergency preparedness
Dentists as health care providers agree to be prepared to prevent recognize and properly manage medical emergencies that may occur in a dental office setting According to the ADA Council on Scientific Affairs examples of common emergencies include seizures cardiovascular and respiratory distress altered consciousness chest pain and drug-related emergencies The Council on Scientific Affairs of the American Dental Association Office Emergencies and Emergency Kits March 2002 (latest version) includes the following recommendations
rsaquo All dentists and appropriate office staff should possess current BLSCPR certification
rsaquo Periodic office emergency drills are encouraged including a well-defined protocol for activating the EMS system
rsaquo Telephone numbers of EMS and other appropriately trained health care providers should be posted
rsaquo The office should have a readily available emergency drug kit and the skills to properly use all of the items it contains andor a plan to handle medical emergencies The drugs should be current and not outdated
The content of the kit is up to each individual dentist but should follow the current recommendations of the ADA Council of Scientific Affairs The Council suggests that the following drugs be included as a minimum
ndash Epinephrine 11000 (injectable)
ndash Histamine-blocker (injectable)
ndash Oxygen with positive-pressure administration capability
ndash Nitroglycerin (sublingual tablet or aerosol spray)
ndash Bronchodilator (asthma inhaler)
ndash Sugar
ndash Aspirin
rsaquo Portable oxygen that can be administered under positive pressure should be able to be delivered to any location in the facility
rsaquo Consult the American Dental Association specialistsrsquo associations and state-specific medical and dental boards for emergency drugs and requirements for
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
27PPO | Dental Office Reference Guide
rsaquo Oral hygiene status
rsaquo TMJ evaluation
Radiographs
Radiographs are an important component of the patientrsquos dental record and all participating dental health professionals should provide radiographs within their office location The frequency and type of radiographs required should be dictated by the patientrsquos clinical status Cigna encourages dentists to prescribe radiographs according to the Guidelines for Prescribing Dental Radiographs (US Department of Health and Human Services (HHS) All radiographs should be of diagnostic quality and either mounted clearly labeled and dated or stored appropriately in an electronic format that meets industry standards
You are required to submit X-rays ONLY on certain procedure codes listed on page 42
Duplication of X-rays ndash Radiographs are generally considered the property of the dentist However your contractual arrangement requires our Network Dentists to make copies of records and radiographs available to Cigna customers or Cigna at no additional cost
If you wish to have x-rays returned to your office please include a self-addressed STAMPED envelope X-rays submitted without a self-addressed stamped envelope will not be returned
Treatment plan
Each patientrsquos chart should contain a full treatment plan signed by the patient which describes the patientrsquos current dental status as well as the procedures (and alternate procedures) recommended to bring the patient to good dental health The patient should receive an explanation regarding the financial obligations associated with the treatment plan Factors such as medical history patient compliance and financial constraints should be noted when they impact the delivery of the treatment plan Further informed consent should be documented Network Dentists should sign the treatment plan in the chart or appropriately update in an electronic storage format that meets industry standards including all subsequent updates to the Plan
rsaquo Malignancy
rsaquo Chronic infection
rsaquo Venereal diseaseherpes
rsaquo Rheumatic fever
rsaquo Bleeding disorders
rsaquo Kidneyliver disease
rsaquo Lungthyroidheart disease
rsaquo Hepatitis
rsaquo Pacemakersheart valve replacement
rsaquo Prosthetic jointship replacement surgery
rsaquo Mitral valve prolapse
rsaquo Medications
rsaquo HIV positiveAIDS
rsaquo Pregnancy
rsaquo Anemia
rsaquo Heart murmur
rsaquo Tuberculosis
rsaquo Use of fen-phen or Redux
Significant elements of medical history including allergies and special precautions necessary for treatment should be displayed prominently on the exterior of each patientrsquos chart
Dental history
The patientrsquos dental record should contain all of the following data relative to the patientrsquos dental status
rsaquo Initial exam findings
rsaquo Recall exam findings
rsaquo Head and neck exam
rsaquo Soft tissue examoral cancer screening
rsaquo Progress notes
rsaquo Informed consent
rsaquo Dental charting of existing restorations
rsaquo Periodontal screening examPSR score
rsaquo Complete periodontal exam and charting if applicable
rsaquo Occlusal analysis
rsaquo Treatment plan
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
28PPO | Dental Office Reference Guide
Additional Guidelines
Provider data changes
Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes within 30 days of the change
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Closing the office to new members
rsaquo Submit request in writing to the Network Management Department
rsaquo Call the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) to find out where to send your request
Terminating your participation
rsaquo Contact the Cigna Dental Provider Service Unit by calling 800Cigna24 (8002446224)
rsaquo Termination requests must be submitted in writing on your company letterhead Please include the providerrsquos name Tax ID number office address and the reason for terminating your Network participation The request must be signed by the contracted dentist
rsaquo Upon receipt of your request Cigna will process your termination with the appropriate notification required under the terms and conditions of your Agreement
Progress notes
Each patient visit should be documented with a note in the patientrsquos chart describing what services were rendered and by whom the clinical outcome and the type and quantity of local anesthetic (or other pharmaceutical) used These notes should be clearly legible written in ink or stored in electronic format that meets industry standards dated and signedinitialed by the practitioner or hygienist
Access to and retention of patientmemberrsquos dental records
The Network Dentist is required to allow Cigna and other Payers or their designee reasonable access to Memberrsquos dental records for appropriate Payer business purposes including dental chart review as part of the Cigna Quality Management Program Cigna other Payers or their designees must also be permitted reasonable access to the PPO Network Dentistrsquos financial records as required to make appropriate reimbursement decisions The Network Dentist is required to retain Membersrsquo clinical and financial records in accordance with federal and state record retention laws
Administrative policies and guidelines (continued)
Dental participation guidelines (continued)
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
29PPO | Dental Office Reference Guide
California
California Senate Bill 853 The Health Care Language Assistance Act requires insurers to establish and support a language assistance program for limited English proficient (LEP) individuals in California To meet the requirements of this law Cigna has developed a California Language Assistance Program (CALAP) that is available to all our customers and network of health care professionals in California Through this program we offer access to free interpreter services and written translation of vital plan documents that can affect a customerrsquos benefits and coverage
rsaquo All patients with Cigna-administered coverage who live in California are eligible for CALAP
rsaquo We do not delegate language assistance services to health care professionals and the use of family and friends as interpreters especially minors should be discouraged
rsaquo All dental health care providers and office staff must offer this vendorrsquos services when speaking to any Cigna plan participant in any non-English language even if someone on staff speaks the language If the plan participant prefers to use a family member or friend as an interpreter after he or she has been told that a trained interpreter is available free of charge this refusal must be documented in his or her medical record (in a health care provider setting) administrative file or call tracking record (in the customer service setting)
rsaquo Forms are available to request or refuse interpretation services in English Spanish and Traditional Chinese These forms can be used by your patients to track their language service preferences regardless of who provides their insurance To access the forms go to the Cigna for Health Care Professionals website (CignaforHCPcom gt Resources gt Forms Center gt Dental Forms gt CALAP ndash Request-Refuse Interpretation Services)
To engage the free interpretation services when the California plan participant is ready to receive services call 8008062059 You will need his or her Cigna ID number date of birth and your TIN to confirm eligibility and access these services It is not necessary to make
arrangements in advance Language preferences will be available to directly contracted dentists upon request through telephone inquiries
Face-to-face interpretation services are available upon request for special circumstances and are handled on a case-by-case basis Please contact 8008062059 to schedule a face-to- face interpreter three to five days in advance
New Mexico
New Mexico law requires health plans to provide free language assistance services to all customers who reside in New Mexico Cigna provides free interpreter services to all dental plan participants in New Mexico who have limited English proficiency or differing hearing abilities that qualify under the Americans with Disabilities Act (ADA) for sign language
Limited English proficiency
Please discourage the use of family and friends ndash especially minors ndash as interpreters Offer the patient a trained qualified telephonic interpreter even if a provider or office staff speaks in the patientrsquos language If a patient insists on using a family member or friend or refuses to use a trained interpreter document this in hisher medical record
If telephonic interpretation services do not meet the needs of your patient in New Mexico with a Cigna-administered plan you can schedule free face-to-face interpreter services by calling Cigna Customer Service at 800Cigna24 (8002446224) For face-to-face Spanish interpreters please allow at least three business days to schedule services For all other languages or to include American Sign Language (ASL) please allow at least five business days to schedule services
Deaf patient
rsaquo Call Cigna Customer Service at 800Cigna24 (8002446224) to schedule an appointment for free sign language interpreter services Provide information about the patientrsquos next scheduled appointment and type of sign language service needed (eg ASL) For ASL interpreters please allow at least five business days to schedule services
Administrative policies and guidelines (continued)
Language Assistance Services
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
30PPO | Dental Office Reference Guide
rsaquo Call 711 Telecommunications Relay Services (TRS) Both voice and TRS users can initiate a call from any telephone anywhere in the United States without having to remember and dial a seven- or ten-digit access number Simply dial 711 to be automatically connected to a TRS operator Once connected the operator will relay your spoken message in writing and read responses back to you In some areas 711 TRS offer speech impairment assistance Specially- trained speech recognition operators are available to help facilitate communication with individuals that may have speech impairments
If a limited English proficiency or deaf patient insists on using a family member or friend or refuses to use a trained interpreter document this in their medical record
Language assistance services for other states
Discounts are available to Cigna-contracted health care providers for language assistance services through CQ Fluency Interpreting Services International (ISI) and Language Line Solutionsreg For more information access our provider website at httpswwwcignacomhealth-care-providersresourceslanguage-assistance-services
Administrative policies and guidelines (continued)
Language Assistance Services (continued)
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
31PPO | Dental Office Reference Guide
Member surveys
The opinions of Members are periodically solicited as to their perceptions of coverage explanations of fi obligations estimated appointment wait times and quality of service rendered at Network Dentistrsquos Office based on
rsaquo Claim payment administration
rsaquo Claim service administration
rsaquo Explanation office obligations
rsaquo Network Dentistrsquos and staffrsquos attitudes
rsaquo Network Dentistrsquos communication of expenses
rsaquo Network Dentistrsquos office environment
rsaquo Network Dentistrsquos management of patient discomfort
rsaquo Perception of treatment outcome
rsaquo Wait time for appointments
rsaquo Wait time in Network Dentistrsquos Office
rsaquo Overall satisfaction with the Dental Plan
rsaquo Overall satisfaction with the Network Dental Office visit
Cigna is committed to responding to Member inquiries and complaints in a timely and fair manner Dental Plan Members may call their claim office to speak with a customer service associate Claim office customer service associates are qualified and trained personnel who are able to resolve andor refer any Member issues
Complaint classifications
Members may have questions related to payment of claims eligibility coverage determinations and other procedural or administrative issues They may also have questions about other aspects of care and services received in your office including your billing policies routine and emergency appointment wait times sterilization protocols or quality of care
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the Credentialing Committee and recommend termination of a particular Network Dentistrsquos agreement
Administrative policies and guidelines (continued)
Member complaints and surveys
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
32PPO | Dental Office Reference Guide
Arizona Appeals should be submitted as follows first level submit within 365 calendar days second level submit within 60 calendar days Responses for appeal submissions should be sent within 30 calendar days
California Single level appeals should be submitted by the NGDNetwork Specialist within 180 calendar days of claim denial Responses for appeal submissions should be sent within 45 business days
New Jersey Providers must initiate an appeal on or before (1) the 90th calendar day following receipt of the adverse determination or (2) the 90th calendar day of a missed due date for the claim determination (including a pended claim) Request for an appeal must be submitted on a form prescribed by the DOBI and is available for download on the Departmentrsquos website at wwwstatenjusdobiindexhtml A written decision of the appeal decision will be communicated to the provider within 30 calendar days after receipt of the appeal on the standardized form If not communicated within the required 30 days the provider may refer the dispute to arbitration
Cigna strives to resolve issues raised by health care providers on initial contact whenever possible
An appeal is defined as a request to change a previous adverse decision made by Cigna when it has been determined by Cigna that the original decision was adjudicated properly
A complaint is considered an initial expression of dissatisfaction from a provider or their representative regarding any issue about coverage service contractual disputes etc
Cigna offers an appeals process for dentist terminations contractual disputes regarding post-service payment denials and payment disputes denial of dentist network participation or when state law requires appeals for other reasons
Before beginning an appeals process please call Cigna Customer Service at 1800Cigna24 (8002446224) or the number on the memberrsquos ID card to try to solve the issue Many issues including denials related to timely filing incomplete claim submissions and contract and fee schedule disputes may be quickly solved through a real-time adjustment by providing requested or additional information If our Customer Service team cannot solve the issue during that call then our appeal process can be initiated through a written request
If a Network Dentist wishes to appeal any decisions he or she must submit the appeal in writing to Cigna The request should be submitted to the following address
Cigna Dental Health Inc PO Box 188044 Chattanooga TN 37422-8044
The Network Dentistrsquos appeal will be reviewed and a decision will be communicated in writing to the PPO dentist within 60 days of the receipt of the appeal Additional time may be required if more information is needed State exceptions apply)
Administrative policies and guidelines (continued)
Provider appeals and complaints
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
33PPO | Dental Office Reference Guide
New York
New York Network Dentists shall provide Cigna with notification of updates to credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
North Carolina
rsaquo Cigna will verify the qualifications of licensed dental health professionals within 60 calendar days from receipt of a completed application for Network participation
rsaquo Recovery of overpayments nonpayment or under-payments is restricted to two years from the date of original claim payment or adjudication as described in NCGS 58-3-225(h)
rsaquo NCGS 58-3-200(b) defines medical necessity as those covered services or supplies that are
ndash Provided for the diagnosis treatment cure or relief of a health condition illness injury or disease and not for experimental investigational or cosmetic purposes
ndash Necessary for and appropriate to the diagnosis treatment cure or relief of a health condition illness injury disease or its symptoms
ndash Within generally accepted standards of medical care in the community
ndash Not solely for the convenience of the insured the insuredrsquos family or the provider
Texas
Dental PPO Plans are not allowed in Texas Cignarsquos Network-based Indemnity Plan is known in Texas as Cigna Dental Choice
Upon written request Cigna will provide Network Dentists with fee schedules and coding information
Virginia
Virginia Network Dentists shall provide Cigna with at least 30 daysrsquo written notice prior to non-acceptance of additional Cigna patients and shall notify Cigna once heshe is available to accept additional Cigna PPO Participants
Colorado
Cigna cannot take adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient satisfaction with pain treatment
Connecticut
Upon leaving the Cigna network for any reason Network Dentists shall provide Cigna with a list of those Cigna patients being treated on a regular basis
Maryland
Maryland has a state-specific referral form Please use this form when referring to a specialist Please contact Customer Service at 800Cigna24 (8002446224) for more information
Minnesota
The term ldquoCertification Numberrdquo in pre-authorization documents is synonymous with either Referral Number or Document Control Number
New Jersey
rsaquo Cigna may recover a refund for overpayment of a claim up to 18 months after the date the first payment on the claim was made This timeframe does not apply to claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits Cigna must provide written documentation that identifies the error made by the carrier in the processing or payment of the claim that justifies the reimbursement request Providers may pursue reimbursement for underpayments for 18 months from the date the first payment on the claim was made unless the claim is subject to an appeal
rsaquo New Jersey GDs may receive a copy of the New Jersey State Health Benefits Program Dental Plan Organization Agreement by calling Customer Service at 800Cigna24 (8002446224)
Administrative policies and guidelines (continued)
State-specific guidelines
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
34PPO | Dental Office Reference Guide
Cigna may include any Network Dentistrsquos name address telephone number office hours languages spoken by the office staff and any other relevant information concerning the Network Dentistrsquos practice in literature or communications to existing or potential Members other dentists Network Rewards Program vendors state regulators groups and other Payers The Network Dentist must not use Cignarsquos name or the name of any subsidiary affiliate or parent company without prior written consent of Cigna
Administrative policies and guidelines (continued)
Use of name
In Arizona Cigna is considered primary for service rendered by the NGD
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
35PPO | Dental Office Reference Guide
Provider credentialing requirements
To participate as a Cigna Network Dentist you must meet certain qualifications The basic criteria with which you must comply in order to be accepted into and continue to participate in the Network include
rsaquo A current license to practice dentistry in the state(s) in which you are applying for participation Upon receipt of your application your licensure status will be verified
rsaquo A current federal Drug Enforcement Administration (DEA) certificate or current state controlled substance certificate (not needed for orthodontists) If you do not have a current federal DEA certificate or current state controlled substance certificate you must provide a back-up plan for prescribing medication to patients when needed
rsaquo Professional liability coverage The dollar amount should be consistent with standards in the dental community You must also indicate any malpractice or liability judgments in the past 10 years and any pending malpractice actions
Specialists must have completed specialty training from a school or program accredited by the American Dental Association (ADA) or recognized as accredited by the ADA
Credentialing review process
Your credentialing information will be reviewed by a credentialing committee to determine whether your qualifications meet established Cigna standards The credentialing committee will at a minimum consist of a dental director compliance analyst a participant of the quality management staff and a network management representative
Review of credentials
The credentials of each Network Dentist will be reviewed on a three-year cycle or more frequently
when appropriate We expect you to assist us with this process by promptly returning information requested by Cigna or its designee including but not limited to a fully completed recredentialing application
New York Network Dentists shall notify Cigna of changes to the above credentialing information demographic information or other material changes including but not limited to languages spoken within the office within 15 days of the change
Recredentialing
As part of our Quality Management Program to ensure our dental network providers continue to meet the highest industry standards for quality oral care and comply with applicable state laws all contracted dental providers are required to participate in the recredentialing process every three years or as needed Providers due for recredentialing will receive a written or electronic notice advising them to complete the recredentialing application and submit certain credentials
If an HCP does not complete the recredentialing application after our initial request there will be a series of scheduled outreaches and follow-ups including additional written attempts and a phone follow-up campaign A provider that still fails to submit the recredentialing application and credentials after these outreaches may be subject to the termination of hisher contract with Cigna Dental
ADArsquos CAQH ProviewTM
This is Cigna Dentalrsquos preferred recredentialing method that allows you to speed up the recredentialing process by completing a CAQH application through the American Dental Associationrsquos credentialing service (httpwwwadaorgcredentialing) powered by CAQH ProView This service is available free of charge to all US practicing dentists and ADA members and non-members alike Once completed
Quality and utilization management are essential components of any network-based Dental Plan Therefore in order to meet the expectations of Members Cigna has a program that monitors utilization and quality
The Cigna PPO and EPO Quality Management Program is comprised of the following components
Quality and utilization management
CAQH ProView is a registered trademark of Council for Affordable Quality Healthcare Inc a non-profit alliance of health plans and related associations CAQH is an independent company and not an affiliate of Cigna Cigna does not endorse any third party products or services and has not independently verified the products or services or any marketing claims made for such products or services Cigna assumes no responsibility and shall have no liability under any circumstances arising out of the use or misuse of such products or services
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
36PPO | Dental Office Reference Guide
Onsite reviews
An onsite review of the Network Dentistrsquos office may be conducted by Cigna or its designee in connection with instances of unusual utilization patterns Member complaints the dental health care provider credentialing process or per state regulations In those instances where an on-site review is indicated it will be conducted by a trained and experienced provider The review may encompass a comprehensive clinical chart review including a review of relevant clinical data such as treatment planning quality and quantity of radiographic data evidence of the diagnosis and treatment of dental disease and adequate application of preventive and diagnostic measures Additionally specific areas to be reviewed at the site visit are
rsaquo Physical and structural facilities
rsaquo Infection control and sterilization protocols
rsaquo Medical emergency preparedness
rsaquo Radiation safety
rsaquo Patient records
rsaquo Patient care assessment
Findings of the on-site review will be evaluated by the dental director or designee for appropriate follow-up and action
Utilization management
Utilization management is a required element of most PPO and EPO programs and some components may be mandated by state regulation Its purpose is to ensure the efficient and appropriate utilization of dental coverage The Utilization Management Program focuses on the following key criteria
rsaquo Frequency of services and procedures
rsaquo Mix of services
rsaquo Necessity and appropriateness of treatment
rsaquo Patient feedback
Please note that Cigna is aware that the data collected is statistical not interpretive and that the utilization management data reveals practice variances but not
the recredentialing process will be seamless (if you keep the attestation and supporting documentation up to date) allowing you to provide multiple health care organizations the ability to access your data thereby reducing the number of different applications you are required to complete
Benefits of using the CAQHrsquos credentialing service
rsaquo A single ldquoprovider profilerdquo that can be shared with authorized plans
rsaquo Maintain information on multiple practice locations and dentists
rsaquo A web-based workflow that flags errors and incomplete information for immediate correction
rsaquo Robust security features to protect data
rsaquo Dentist support via phone and live chat
These items are necessary to complete your credentialing application with CAQH ProView
rsaquo A copy of your state license and specialty license (if applicable)
rsaquo A copy of your professional liability insurance face sheet or certificate of insurance
rsaquo Practice information
rsaquo NPI Number
Additional documents may be required
You can also visit ADAorgcredentialing to learn more Need help or have questions Call the ADA at 8006218099 or email mscadaorg
If you have not completed your recredentialing application in advance with the CAQH profile you can still use this option to comply with the recredentialing process notice Visit wwwCAQHorg or call the CAQH Help Desk at 18885991771 Once your application is completed and attested please enter your CAQH ID and fax it to Cigna at 8602633938
If you have any questions about the recredentialing process send an email to DentalRecredentialingCignacom or call 18556298584
Quality and utilization management (continued)
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
37PPO | Dental Office Reference Guide
the reason for them Furthermore Cigna does not assume that specific variances are inappropriate The Utilization Management Program may include the following processes
Predetermination of coverage (elective) and claims review (retrospective)
Cigna Network Dentistsrsquo requests for coverage predetermination or claims for payment undergo a review process that begins with a basic automated screening of treatment plans and may include professional review of complex treatment plans
Statistically based utilization management review
Cigna develops norms of utilization and generates specific reports on Network Dentists from claims submitted for payment Utilization patterns for each Network Dentist will be compared to the norms established by Cigna in order to identify those dental health professionals who deviate significantly from the established norms for particular procedure codes
Utilization patterns outside the norm
Cigna may provide written notice to the Network Dentist if Cigna considers the Network Dentist to have utilization patterns that deviate significantly from the established norms Such notice shall include the specific reasons for the determination by Cigna with regard to utilization patterns and supporting documentation
Follow-up
Utilization management will result in appropriate follow-up by Cigna for those Network Dentists whose utilization patterns deviate from the norm Follow-up with the Network Dentist may include but is not limited to informational letters procedural descriptions and coding guidelines references to professional literature and requests by Cigna for written or verbal explanations of utilization patterns which are outside of the norm Initial statistical assessments may be followed up by direct communication with the PPO dentist for evaluation of other factors which may impact utilization patterns In some cases Cigna may find it necessary
to arrange a clinical examination of a Member by a practicing dentist consulting for Cigna Cigna reserves the right to do so in instances when the necessity appropriateness andor quality of treatment are questioned andor when such exams may be necessary to resolve Member andor Network Dentist complaints
Determination
Cigna will consider the Network Dentistrsquos utilization patterns and the results of follow-up with the Network Dentist in its determination as to whether or not a dentist will continue as a Network Dentist
Inquiry and complaint process
Inquiries may be received in the claim office by telephone or in writing We are committed to responding to telephone inquiries during the same call whenever possible If we need more time to review or investigate the matter we will get back to the Member as soon as possible We are committed to responding to written complaints within 30 days (state exceptions apply) An internal appeals process is available for Members and dental health professionals In certain situations where medical necessity determinations are questioned an external review process may be available All complaints are carefully investigated and tracked until completion and thereafter for trending purposes Documentation is collected maintained and reviewed by dental directors particularly for Network Dentists with practice patterns that appear to deviate from norms As part of the complaint resolution process the dental director may request additional information request an onsite office review refer the issue to the credentialing committee and recommend termination of a particular Network Dentistrsquos Agreement
Quality and utilization management (continued)
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
38PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program
Research shows that a personrsquos oral health may have an impact on his or her overall health This may be especially true for people who have certain medical conditions That is why we offer 100 reimbursement of copayments and coinsurance on certain dental procedures for customers with specific medical conditions We also offer savings on certain prescription dental products and guidance on behavioral issues that impact oral health
Patients eligible to participate in the program
Most Cigna Dental customers are eligible for program participation regardless of their medical carrier The only requirement is that they must have one of the medical conditions listed below Your patient can confirm eligibility by calling Customer Service at 800Cigna24 (8002446224)
rsaquo Heart disease or stroke rsaquo Chronic kidney disease
rsaquo Diabetes rsaquo Organ transplant
rsaquo Maternity rsaquo Head and neck cancer radiation
To determine the procedures for which your Cigna Dental insured patients may qualify for 100 reimbursement of copayments or coinsurance from Cigna Dental refer to the table below Unless noted normal age and frequency limitations apply
1 Eligibility reimbursement and coverage for eligible services are subject to plan year maximums 2 Four times per year3 One additional evaluation
4 One additional cleaning5 No limitations6 Age limits removed all other limitations apply
Medical Conditions (check mark indicatesMedical conditions (check mark indicates covered dental service1)
Procedure Heart disease Stroke Diabetes Maternity
Chronic kidney disease
Organ transplants
Head and neck cancer
radiation
Periodontal treatment and maintenance (D4341 D4342 D4910)
Periodontal evaluation (D0180)
Oral evaluation3 (D0120 D0140 D0150)
Cleaning4 (D1110)
Scaling in the presence of inflammation ndash full mouth4 (D4346)
Emergency palliative treatment6 (D9110)
Topical application of fluoride varnish6 (D1206)
Topical application of fluoride6 (D1208)
Sealants6 (D1351)
Sealant repair ndash per tooth6 (D1353)
The program benefits apply when a patientrsquos dental plan does not pay 100 for the procedure or plan coverage for the procedure has been exhausted Deductible does not apply Reimbursement counts toward maximum for DPPOindemnity plans
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
39PPO | Dental Office Reference Guide
Cigna Dental Oral Health Integration Program (continued)
Provider reimbursement
Follow the same procedure you normally would Bill the patient according to his or her plan after performing the covered procedure Bill DHMO plan participants for their copay and DPPO plan participants for their coinsurance Provide your patient with an itemized receipt as you usually do for any covered dental service you provide Then submit your claim to Cigna Dental
Member reimbursement
Your patient must complete the Cigna Dental Oral Health Integration Program ldquoRegistration Formrdquo The registration form is available on myCignacom Cignacom or by calling the number on the ID card Once registered your patient simply visits your office and pays the usual copayment or coinsurance amount for the covered procedure Cigna will automatically send the reimbursement to the member within 30 days
Can I tell my patients about the program
Yes we encourage dentists to ask patients about their medical conditions to see if they are eligible for the program Help your patients maintain a healthy mouth after they leave your office and share all the benefits of the Oral Health Integration Program with them ndash including discounts and educational articles Your awareness of this program and assistance with members who qualify will help them take full advantage of additional plan features Together we can make sure proper dental care is given to those who truly need it most
Questions
If you have any questions about the program please reach out to your Cigna Dental Professional Relations Manager or call Customer Service at 800Cigna24 (8002446224)
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
40PPO | Dental Office Reference Guide
Clinical policies and guidelines
Clinical coverage determination guidelines
Information about the Cigna Dental Clinical Coverage Determination Guidelines relied upon in making an adverse benefit determination is available immediately at CignaforHCPcom gt Resources gt Reference Guides You may also request this information by contacting Customer Service at 800Cigna24 (8002446224) A copy will be provided to you or your authorized representative free of charge
Comprehensive periodontal evaluations
After an initial covered D0180 (comprehensive periodontal evaluation ndash new or established patient) has been allowed the Plan coverage for any subsequent evaluation by the same dental health professionaloffice performed on the same Cigna Member is based on the allowance for a D0120 (periodic oral evaluation ndash established patient) The Member is responsible only for those costs associated with the D0120 up to the dental health professionalrsquos Contract Fee If an established patient has a seriousmajor change in medical history the D0180 may again be allowed upon submission of a narrativerationale (a letter from the Memberrsquos physician may also be required)
Emergency care
Policy
Network General Dentists and Specialists shall provide or arrange for emergency coverage on a 24-hour-per-day 7-day-per-week basis such that members shall receive emergency care relating to their services within 24 hours of contacting the dental office or within such lesser time as may be medically indicated
While this policy requires that emergency care be made available to Cigna members within 24 hours of contacting the dental office or within 24 hours if medically indicated this policy in no way limits emergency care only to the first 24 hours after the member contacts the dental office
Definition
A ldquodental emergencyrdquo is defined as a dental condition of recent onset and severity that would lead a sensible layperson possessing an average knowledge of dentistry to believe that hisher condition requires immediate dental treatment necessary to control excessive bleeding relieve severe pain or eliminate acute infection Examples include
rsaquo An injury to the mouth area causing significant bleeding severe pain or acute infection
rsaquo The loss of a large filling in a tooth loss of a crown or a cracked tooth that results in significant acute pain and discomfort
rsaquo Swelling in the mouth area that is the result of an infection normally associated with an abscess
A true ldquodental emergencyrdquo is one in which the member describes their situationevent to be a condition that needs immediate attention
Infection control
All participating dental health care providers should follow Centers for Disease Control and Prevention (CDC) guidelines and the Occupational Safety and Health Administration (OSHA) standards and any applicable state recommendations for sterilization andor infection control Cigna considers sterilization infection control traysetup and the handlingdisposal of biohazardous waste to be included as part of the delivery of dental services and patient care Therefore neither the patient nor Cigna may be charged separately for these services
Biological monitoring ldquospore testingrdquo of each autoclave or heat sterilization device is recommended weekly and required at a minimum once a month unless state regulations mandate otherwise Spore testing of sterilizers must be validated by a third-party vendor Please check the Cigna Network Rewards Program for vendors that may offer discounts on these services
In order to increase Plan satisfaction among Members the Cigna PPO and EPO have established policies and procedures for Network Dentists and their office staff to allow the Cigna PPO and EPO to operate smoothly and deliver quality customer service to our Members For more information on PPO dental procedure coverage guidelines visit CignaforHCPcomResourcesReference GuidesDental Reference GuidesPPO Coverage Determination Guidelines
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
41PPO | Dental Office Reference Guide
Periodontal regenerative procedures
Coverage for only one periodontal regenerative procedure per site (or per tooth if applicable) is allowed The patient and dentist are the best decision makers regarding dental care and any services that the patient and dentist deem appropriate beyond this allowance are the patientrsquos payment responsibility at the dentistrsquos Contract Fee
Specialty recommendations
Although Cigna PPO Plans have an out-of-network option use of Network Dentists usually results in cost savings for Members Referrals to a specialty dentist are not required and do not need prior approval under the Cigna PPO Plans and because EPO Plans are in-network only there is no out-of-network coverage If you want to recommend a specialist within the Cigna PPO Network we request that you call Customer Service at 800Cigna24 (8002446224) or visit Cignacom for a listing If you choose to recommend a specialist who is not in the Network we request that you advise Members that their financial responsibilities may be affected by this selection and that they should consult their certificate booklet or call the claim office for specific information If the specialist you use most often would like to consider joining the Cigna PPO Network please ask him or her to contact us the Cigna Dental Provider Service Unit at 800Cigna24 (8002446224) or visit Cignacom to submit the request
Clinical policies and guidelines (continued)
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
42PPO | Dental Office Reference Guide
Clinical policies and guidelines (continued)
Radiographs
Recommendations for prescribing dental radiographs These recommendations are subject to clinical judgment and may not apply to every patient They are to be used by dentists only after reviewing the patientrsquos health history and completing a clinical examination Even though radiation exposure from dental radiographs is low once a decision to obtain radiographs is made it is the dentistrsquos responsibility to follow the ALARA (as low as reasonably achievable) Principle to minimize the patientrsquos exposure
New patient being evaluated for oral diseases
Individualized radiographic exam consisting of selected periapicalocclusal views andor posterior bitewings if proximal surfaces cannot be visualized or probed Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment
Individualized radiographic exam based on clinical signs and symptoms
Recall patient with clinical caries or at increased risk for caries
Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 6- to 18-month intervals
Not applicable
Recall patient with no clinical caries and not at increased risk for caries
Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
Posterior bitewing exam at 18- to 36-month intervals
Posterior bitewing exam at 24- to 36-month intervals
Not applicable
Recall patient with periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease Imaging may consist of but is not limited to selected bitewing andor periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Not applicable
See page 42 Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0ndash6 years of age and over 6 years of age)From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
When the allowance for a combination of X-rays (such as ten or more periapical X-rays or a panoramic X-ray with bitewings) on the same date of service meets or exceeds the allowance for intraoral complete series of X-rays plan reimbursements will be based on an intraoral complete series procedure code D0210
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
43PPO | Dental Office Reference Guide
Patient (new and recall) for monitoring of dentofacial growth and development andor assessment of dentalskeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of dentofacial growth and development or assessment of dental and skeletal relationships Panoramic or periapical exam to assess developing third molars
Usually not indicated for monitoring of growth and development Clinical judgment as to the need for and type of radiographic image for evaluation of dental and skeletal relationships
Patient with other circumstances including but not limited to proposed or existing implants other dental and craniofacial pathoses restorativeendodontic needs treated periodontal disease and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation andor monitoring of these conditions
Clinical policies and guidelines (continued)
Radiographs (continued)
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Type of encounter
Child with primary dentition (before eruption of first permanent tooth)
Child with transitional dentition (after eruption of first permanent tooth)
Adolescent with permanent dentition (before eruption of third molars)
Adult dentate or partially edentulous
Adult edentulous
Recommendations for prescribing dental radiographs (continued)
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
44PPO | Dental Office Reference Guide
From American Dental Association US Food amp Drug Administration The Selection of Patients for Dental Radiograph Examinations Available on wwwadaorg
Recommendations for prescribing dental radiographs (continued)
A Positive historical findings
1 Previous periodontal or endodontic treatment
2 History of pain or trauma
3 Familial history of dental anomalies
4 Postoperative evaluation of healing
5 Remineralization monitoring
6 Presence of implants previous implant-related pathosis or evaluation for implant placement
B Positive clinical signssymptoms
1 Clinical evidence of periodontal disease
2 Large or deep restorations
3 Deep carious lesions
4 Malposed or clinically impacted teeth
5 Swelling
6 Evidence of dentalfacial trauma
7 Mobility of teeth
8 Sinus tract (ldquofistulardquo)
9 Clinically suspected sinus pathology
10 Growth abnormalities
11 Oral involvement in known or suspected systemic disease
12 Positive neurologic findings in the head and neck
13 Evidence of foreign objects
14 Pain andor dysfunction of the TMJ
15 Facial asymmetry
16 Abutment teeth for fixed or removable partial prosthesis
17 Unexplained bleeding
18 Unexplained sensitivity of teeth
19 Unusual eruption spacing or migration of teeth
20 Unusual tooth morphology calcification or color
21 Unexplained absence of teeth
22 Clinical tooth erosion
23 Peri-implantitis
Clinical situations for which radiographs may be indicated include but are not limited to
Clinical policies and guidelines (continued)
Radiographs (continued)
Procedure codes that require submission of X-rays
Restorative Services
D2335 D2542 D2543 D2544 D2642 D2643 D2644 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2929 D2930 D2931 D2932 D2933 D2934 D2950 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2975
Endodontic Services
D3221 D3331 D3333 D3351 D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3431 D3432
Periodontic Services
D4212 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4341 D4342 D4346 D4381
Prosthodontic Services
D5863 D5864 D5865 D5866
Implant Services
D6010 D6013 D6053 D6054 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6081 D6082 D6083 D6084 D6086 D6087 D6088 D6094 D6097 D6098 D6099 D6103 D6104 D6110 D6111 D6112 D6113 D6114 D6115 D6116 D6117 D6118 D6119 D6120 D6121 D6122 D6123 D6194 D6195
Prosthodontic Fixed Services
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6243 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6753 D6780 D6781 D6782 D6783 D6784 D6790 D6791 D6792 D6793 D6794 D6970 D6971 D6972 D6973 D6975 D6976 D6977
Oral and maxillofacial surgery service codes
D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7285 D7286 D7296 D7297 D7510 D7511
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
45PPO | Dental Office Reference Guide
Submission of X-rays for crown codes is required for anterior teeth only Also submission of X-rays for extraction codes on teeth 1 16 17 and 32 is required for patients under age 15 only
Cigna reserves the right to request additional X-rays on these and other procedures as deemed necessary for claims payment
Policy and rationale
The Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association (ADA) has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is recognized by third-party payers nationwide According to the ADArsquos CDT 2020 Coding Companion Help Guide for the Dental Team the codes are ldquoprocedure based rather than instrument basedrdquo
Hence Cigna PPO members cannot be charged for the specific use of equipment or instruments (including but not limited to handpieces air abrasion lasers CADCAM technology) in the completion of a dental service The use of equipment to complete a procedure is considered inclusive of the applicable CDT procedure codes Members may only be charged the applicable coinsurance for the dental procedure(s) based upon your Cigna fee schedule
CDT 2020 Coding Companion Help Guide for the Dental Team American Dental Association p 87
Clinical policies and guidelines (continued)
Radiographs (continued)
Clinical policies and guidelines (continued)
Use of equipment
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
46PPO | Dental Office Reference Guide
Contact information
All of the phone numbers and addresses that you may need to contact Cigna Dental are listed below Please note that based on the patientrsquos ID card call claim and service channels may differ
If you want to Use the following
Submit your claims Submit patient encountersclaims electronically using Cigna payer ID 62308
Submit paper claims to
Cigna PO Box 188037 Chattanooga TN 37422-8037 Attn Claims
Access Cigna for Health Care Professionals website for online transactions
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo View payment guidelines
rsaquo Obtain a PPO Dental Office Reference Guide
rsaquo View claim details and payment information
rsaquo Downloadprint explanation of payments
rsaquo Get forms for dental office changes
rsaquo Enroll for or make changes to EFT
rsaquo View the Cigna Network Rewards Programreg vendors and discounts
rsaquo Other information resources
Cigna for Health Care Professionals website at CignaforHCPcom
Dental Office Change Forms available online
Dentist Change Form Use this form to change your office or mailing address Taxpayer Identification Number (TIN) or ldquoPayable tordquo name (This form should only be used to report dental office changes not to add a new location)
W-9 Complete this form if you change your TIN or ldquopayable tordquo name and accompany it with a Dentist Change Form
NewAdditional Location Form Use this form to add a newadditional location to your existing contract with Cigna
Direct Deposit Authorization Form If you change your TIN address or ldquopayable tordquo name and receive electronic funds transfer (EFT) payments from Cigna you will need to complete this form with the new information
Make Electronic Data Interchange (EDI) transactions using a multi-payer website or vendor
rsaquo Verify patient eligibility
rsaquo Check patient coverage and covered services
rsaquo Submit claims electronically
rsaquo Check the status of a claim
rsaquo Receive electronic remittance advices
rsaquo View list of EDI vendors
Refer to CignacomEDIvendors for a list of directly connected Cigna vendors
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
47PPO | Dental Office Reference Guide
If you want to Use the following
Make telephone inquiries through the Cigna Customer Service Center
rsaquo Verify patient eligibility and coverage
rsaquo Check the status of a claim
rsaquo Request precertification of services
Call the Customer Service Center toll-free at 800Cigna24 (8002446224) or the number on the patientrsquos ID card to speak to a Customer Service Associate
Obtain assistance specifically tailored to the needs of a health care provider if escalation of an issue is necessary or if there are any network participation issues
rsaquo Dental office changes
rsaquo Direct depositEFT
rsaquo Copies of contracts
rsaquo Copies of fee schedules
rsaquo Missing PPO checks
rsaquo Status of applications
rsaquo Office not listed in directory
rsaquo Other consultations
Contact the Cigna Dental Provider Services Unit (PSU) at 800Cigna24 (8002446224)
Through the voice prompts identify yourself as a health care professional enter your tax identification number request contracting and identify yourself as a dental caller
Or send an email to ProviderServiceUnitDentalCignacom
Join a Cigna Dental network or add a new health care provider to your office
Send an email to DentistEnrollmentCignacom
Escalate claims only (not for initial claim submission)
Send an email to DentalHCPInquiryCignacom
AppealComplaints Send a written request to
Cigna National Appeal Unit PO Box 188044 Chattanooga TN 37422-8044
Further escalate the following transactions
rsaquo Claims
rsaquo Other consultations
Contact your designated Provider Relations Manager
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Provider Relations Team
Access Provider Relations resources across the Dental network and markets
Contact the designated Provider Relations Director
For territory assignments log in to CignaforHCPcom gt Resources gt Dental Resources gt Doing Business with Cigna gt Professional Relations Team
Contact information (continued)
Excluding customers with third party administrator plans Not all transactions are available for all Cigna plans
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
48PPO | Dental Office Reference Guide
Notes
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
All CDT Codes are from Code on Dental Procedures and Nomenclature a copyrighted publication provided by the American Dental Association The American Dental Association does not endorse any codes which are not included in its current publication
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation Cigna Dental PPO plans are insured or administered by Cigna Health and Life insurance Company or Connecticut General Life Insurance Company with network management services provided by Cigna Dental Health Inc and certain of its subsidiaries In Texas the insured dental plan is known as Cigna Dental Choice and this plan uses the national Cigna DPPO network The Cigna name logo and other Cigna marks are owned by Cigna Intellectual Property Inc All pictures are used for illustrative purposes only
552684 r 0320 copy 2020 Cigna Some content provided under license
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