QUALITY STANDARDS
NetClaim Solutions utilization review guidelines are based on recommendations and standards developed by dental professional organizations, and regulatory bodies to guide dental practitioners in delivering high-quality care. These guidelines explain the criteria that we use to adjudicate pre-treatment estimates, post-review requests, and/or claims.
These guidelines promote best practices, ensure patient safety, and improve oral health outcomes.
Dental guidelines cover a wide range of topics and areas within dentistry, including:
- Prevention and Oral Health Promotion: Guidelines address preventive measures such as oral hygiene practices, fluoride use, and patient education on maintaining good oral health.
- Diagnosis and Treatment Planning: Guidelines provide recommendations for accurate diagnosis, assessment, and treatment planning for various dental conditions. This includes guidelines for dental examinations, radiographic imaging, and the interpretation of diagnostic findings.
- Restorative Dentistry: Guidelines outline evidence-based approaches for restoring and replacing teeth, including the use of dental materials, and techniques for dental fillings, crowns, bridges, and dental implants.
- Periodontics: Guidelines focus on the prevention, diagnosis, and treatment of gum diseases (periodontal diseases) and provide recommendations for periodontal therapy, including scaling and root planning, periodontal surgery, and maintenance of periodontal health.
- Endodontics: Guidelines cover root canal treatment, addressing proper diagnosis, disinfection techniques, instrumentation, and the restoration of endodontically treated teeth.
- Oral and Maxillofacial Surgery: Guidelines provide recommendations for surgical procedures involving the mouth, jaw, and face, such as extractions, wisdom tooth removal and dental implants.
- Pediatric Dentistry: Guidelines focus on dental care for infants, children, and adolescents, including preventive measures, treatment of dental caries, growth and development monitoring, and behavior management techniques.
- Dental Emergency Management: Guidelines offer recommendations for managing dental emergencies and acute dental conditions, such as dental trauma, tooth avulsion, dental pain, and infection control in emergencies.
All our clinical decisions are performed ethically, following the Standard of Care in Dentistry guidelines of the American Dental Association by dental consultants with an active license in Puerto Rico who are members of the Colegio de Cirujanos Dentistas de Puerto Rico.
Administrative Guidelines
- The guidelines described in this document do not represent the member’s benefits approved by the plan.
- The provider has the responsibility to validate the plan-approved member’s benefits before rendering the services.
General Review Guidelines
- All narratives must include the patient’s signs and symptoms that support the proposed treatment.
- Include a narrative when necessary to support the procedure or service, even if is not required specifically by the guidelines.
- All radiographs should be labeled with the patient’s name and must be of diagnostic quality. Periapical films and all x-rays for crown/bridge must show the apex of the tooth/teeth.
- Bitewing X-rays are not acceptable for crown and bridge.
- All submitted radiographs must be the correct type for the submitted procedure.
- All X-rays must identify right (R) or left (L).
- Post-operative periapical x-rays of completed root canal treatments will be required when a core build-up, post and core, and crown are placed.
- Charting must include 6-point probing for scaling root planning and other surgeries. Recession and the amount of gingiva for grafting procedures must be charted.
- The periodontal surgery history must be documented to support the benefit of D4910.
- Copy of the primary plans Explanation of Payment (EOP) must be attached to the claim form for the secondary payer, for coordination of benefits purposes.
- If it is determined that submitted services were unbundled, they will be re-bundled to the appropriate code contracted amount.
- If determines that a less expensive alternate procedure, service, or course of treatment can be performed in place of the proposed treatment to correct a dental condition, and the alternate treatment will procedure a professionally satisfactory result, then the maximum will allow will be the charge for the less expensive treatment.
- Refer to the guidelines for specific procedure codes regarding submission and supporting documentation requirements.
