Meeting with Adriana Amorim – Delta Dental of MA

We were delighted to have Adriana Amorim from Delta Dental of Mass. come to our outsourcing office for an informational session. She is a wonderful resource for us as we represent our clients with their questions and concerns about Delta.

I want to share some of the highlights with you:

1. Re-credentialing is done every 3 years.  Five months before a doctor’s credentialing expires, a letter will be sent to the address on file listed as correspondence address.  The correspondence address is obtained upon credentialing and may be updated at any time upon written request. The correspondence address might not be where they are practicing now, so doctors may want to use their home address for any correspondence from Delta.

2.  X-rays must be of diagnostic quality.  Intraoral photographs do not replace x-rays.  They may be sent but not in lieu of x-rays. 

3.  COB – Medical insurance will always be primary for any oral surgery.  You need either a denial EOB from medical or, if there is no coverage under the medical insurance, the words “No medical coverage” in Box 35 on the claim.  Always confirm that there is no medical before you submit a claim with that wording.

4. Keywords for Box 35: These words will flag a claim to ensure that it gets looked at promptly. The key word must be the first word written in box 35: 

  • COB – no medical coverage
  • Corrected 
  • Reconsider
  • Prior perio history

5.  Many of our practices have received notification of a “Focused Review”.  The focus of these visits is to look at highly utilized procedures in comparison to other providers in that area.

6.  If a narrative is requested or required it may not take the place of chart notes.  Sending both is okay but chart notes alone may not be enough.

7.  Anterior teeth treated endodontically may only be approved for a filling and may not be approved for a crown.  Adriana recommends looking at the Participating Provider Procedure Manual for more detail on criteria for coverage

8.  The claim form must always match the case notes and posting in the patient account.  If an exam is posted to a hygienist in the account and Delta does an audit this will be flagged.

The following are “red flags” for abuse:

  • X-rays-utilization and quality
  • SRP-necessity and actual services
  • Build ups and crowns-necessity

10.  Perio maintenance (D4910) is covered as long as the patient meets the requirements, but they must show consistent visits for perio cleanings.  If they drop off for a period of time, they will need to be re-evaluated, and may not be eligible for D4910, unless patient is retreated with SRP if necessary.  Sending history is key.

As always, benefits are subject to policy guidelines.  Benefits are not a guarantee of payment.  The above is informational and not intended for benefit determination or promise of payment.

Intel from Outsourcing

Leave a Reply