Important Policy Notification United Concordia FedVip

Important Policy Notification United Concordia FedVip

Updated Periodontal Scaling and Root Planing Policy for

FEDVIP Members  (now being enforced regularly–2016)

Effective January 1, 2012, general dentists and non-periodontal specialists must submit diagnostic materials for all periodontal scaling and root planing (PSRP) claims (D4341 and D4342) for FEDVIP members, regardless of the

patient’s age.

The updated policy applies to services provided by general dentists and non-periodontal specialists in all 50 states, but

does not apply to the TRICARE Dental Program (TDP), the Active Duty Dental Program (ADDP), Gateway Health Plan or

PA CHIP.

If you are a general dentist or a non-periodontal specialist, please do not submit claims for procedure codes D4341 or D4342 without providing the diagnostic materials required for professional review, including:

  • Full mouth duplicate radiographs or digital images
  • Full mouth charting, including 6 points per tooth
  • Detailed narrative describing clinical findings

For treatment to be considered a covered benefit, diagnostic materials must demonstrate:

  • Clinical loss of periodontal attachment
  • Radiographic evidence of crestal bone loss or changes in crestal lamina dura
  • Bleeding points and/or radiographic evidence of root surface calculus

If these criteria are not evident upon professional review, the claim for PSRP cannot be approved. If you have questions regarding this policy, please contact our Customer Service Department toll-free at (800) 307-8514.

 

The diagnostic materials requested here for FedVip are becoming increasingly necessary for many insurance companies since this inception date.  Particularly is the demand for clinical notes and evidence of medical necessity in the health history of the patient.

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