Frequently Asked Questions
Q. Does the Plan Administrator accept electronic claims?
A. Yes, we accept electronic claims through Emdeon and G&C. The Plan Payer ID can be found on the back of the Member ID card.
Q. What if I use a clearinghouse other than Envoy, CPS, or Healtheon/WebMD (formerly MedeAmerica)?
A. The Plan Administrator accepts claims through Emdeon, MDE and G&C.
Q. How do I submit claims to the Plan Administrator?
A. Claims can also be mailed to the address on the back of the member ID card or faxed to 540.562.8038
Q. What should be included on claim forms to the Plan Administrator?
A. Be sure to include the following on all claim forms:
- Member's name, date of birth and identification (ID) number
- Patient's name and date of birth
- Patient’s relationship to member
- The dentist's complete license number
- The dentist’s EIN (TIN or SSN)
- National Provider Identifier (NPI)
- Narratives, X-rays and intra-oral photos
- Dates of service (completion or delivery dates) for multiple visit services
- Tooth numbers or quadrants - indicate tooth surfaces where applicable
- Complete other coverage information including other carrier member name, date of birth, ID number and attach other carrier Explanation of Benefits if applicable
Q. Should I also send a paper claim to the Plan Administrator if I have sent one electronically?
A. No. To ensure quick processing, please don't submit both paper and electronic claims.
Q. How do I check the status of a claim?
A. You can check the status of your claims by calling the number on the back of the member ID card.
Q. Does the Plan Administrator accept electronic attachments?
A. Yes, we accept electronic attachments through National Electronic Attachments (NEA). Please note, the attachment must be sent with an electronic claim. If you receive a "Request for Additional Information" you may submit an electronic attachment without a claim if you submit the claim number with the attachment. Please do not send an electronic attachment without a claim or without reference to a specific claim number when sending requested additional information.
Q. How do I find out more about filing electronic attachments from my office?
A. In order to submit electronic attachments, you will need equipment that produces an electronic copy of a document or image. The type of equipment and other requirements depends on which vendor you choose to support this capability.
Q. Which procedures require radiographs?
A. The following procedures require radiographs be submitted with the claim:
- Some periodontal procedures
- Surgical extractions
- Crowns, core buildup, cast or prefab post and core
- Partial dentures
- Inlays, onlays and veneers
If you have any questions about whether a specific procedure requires radiographs to be submitted with the claim, please call Benefit Services at the number listed on the back of the Member ID card.
Radiographs should mounted, dated, labeled left to right or with tooth numbers and identified on the X-ray with the patient name, dentist name and the dentist's address and phone number.
Radiographs will not be returned unless submitted with a self addressed return envelope. Make sure to send copies of your original X-rays. The Plan Administrator is not responsible for returning X-rays.
Q. Which procedures require narratives?
A. The following procedures require narratives be submitted with the claim:
- 9110 - Palliative (emergency) treatment of dental pain
- 2950 - Core buildup, including any pins
- 4355 - Full mouth debridement
- 4210,4211 - Gingivectomy or Gingivoplasty
- 9940 and 7880 - indicating Bruxism or TMJ
- Implants - indicating medical necessity
- Any procedure code ending in 99 – Miscellaneous codes
- Other procedures that are unclear or require dental necessity rationale
Q. What procedures require periodontal charting?
A. The following procedures require periodontal charting: CDT Codes 4210, 4211, 4220, 4240, 4260, 4263, 4264, 4266, 4267, 4270, 4271, 4273, 4341 and 4342.
Q. What is the correct date of service for multiple visit procedures like root canals, crowns, fixed and removable prosthetics?
A. The correct date of service is the final fill date, the cementation date and/or the delivery date. The Plan Administrator will only pay for completed dental services.
Q. Does the Plan administer network plans?
A. The Plan doesn't own a proprietary network, but does contract with networks to service clients with network dental plans. Please look at the Member ID card to determine if their plan participates with any networks, or call Benefit Services at the number listed on the back of the Member ID card.
Q. How do I determine patient benefits and eligibility?
A. You can access benefits for your patient quickly and easily by calling Benefit Services at the number listed on the member ID card.