December 2011

PacificSource Renews Commitment to Dental Market, Welcomes New Dental Director

We are pleased to introduce Jim Gimarelli, D.M.D., to the PacificSource team as Director of Dental Business. Under Jim’s leadership, we have formed a dedicated dental product team to develop and focus on our vision and strategy for our dental products and to assess the needs of the marketplace.

“A renewed focus on dental products, combined with our strong reputation for customer service and unique partnership with Advantage Dental will provide some exciting opportunities,” says Troy Kirk, PacificSource Regional Senior Vice President and Chief Marketing Officer.

Jim joined PacificSource in April in our Springfield, Oregon, office, coming to us from Assurant Employee Benefits, where he served as Vice President of Dental. Prior to Assurant, Jim ran Standard Insurance Company’s Oregon dental business along with managing the claims areas for dental, life and waiver products, and was director of underwriting for Delta Dental of Minnesota. He also served as an officer in the U.S. Army Dental Corps at Fort Bragg, N.C. and Fort Lewis, WA. Jim earned a bachelor’s degree from Portland State University and his D.M.D. degree from the Oregon Health Sciences School of Dentistry. He and his family live in Eugene and are avid Oregon Duck fans.

“I am excited for this opportunity at PacificSource,” says Jim. “In my short time here, I have developed an appreciation for the way PacificSource really cares about its members. Many other insurance companies talk about this, but PacificSource lives it each and every day.”

Jim points out that the connection between dental health and overall medical well-being is significant. “We look forward to growing our dental block and making a positive impact on overall medical health at the same time. Additionally, the partnership that we have with Advantage provides both of us many opportunities to work together and enhance the quality of care in the field of dentistry. With healthcare reform on the horizon, this partnership will be a critical component for us going forward.”

Dr. Gary Allen Provides Dental Consulting Expertise

This past June, PacificSource began using the dental clinical consultation services of Dr. Gary Allen. This arrangement, through our partnership with Advantage Dental, helps ensure that we provide high quality, cost-effective care for our dental members.

Dr. Allen has extensive experience in dentistry, including 11 years as Director of QI and Dental Director for Willamette Dental Group and 26 years in the U.S. Army, from which he retired as a Colonel in 1999.

He graduated from the University of Oregon Dental School and holds a master of science degree in oral biology from George Washington University.

Prior Authorizations Help Avoid Surprises

To help avoid unexpected delays, expenses, and claim denials, we recommend prior authorization for certain major, nonemergent services. Examples of services that should be submitted for prior authorization include (but are not limited to) those listed below. When requesting prior authorization, please include sufficient clinical documentation to determine eligibility and medical necessity. We appreciate your cooperation.

If you have any questions regarding prior authorizations, feel free to contact our Dental Customer Service Department at (866) 373-7053 or dental@pacificsource.com.

We Encourage Prior Authorization for the Following Services*

Update - December 15, 2011: All of the services below, except for D4341, D4342, and D7220, will require prior authorization beginning with dates of service on or after January 1, 2012. To request authorization for these services, you may use the ADA Dental Claim Form and mark the "Request for pre-determination/preauthorization" box.

Code	Procedure	Requested Clinical Documentation
D4249	Crown lengthening	Diagnosis, current periapical or BW radiograph, and relevant clinical findings
D4260	Osseous surgery 4 or more teeth	Diagnosis, periodontal charting with probings done within past 12 months, current periapical radiographs, and relevant clinical findings
D4261	Osseous surgery 1-3 teeth
D4270	Pedicle soft tissue graft	Diagnosis, periodontal charting with probings done within past 12 months, and relevant clinical findings
D4271	Free soft tissue graft
D4273	Subepithelial connective tissue graft
D4275	Soft tissue allograft
D4341	Scaling and root planing 4+ teeth	Diagnosis, periodontal charting with probings done within past 12 months, most recent full mouth or vertical BW radiographs, and relevant clinical findings (Please see article below for more information.)
D4342	Scaling and root planing 1-3 teeth
D7220	Surgical removal impacted tooth – soft tissue	Diagnosis, current periapical or panoramic radiograph, and relevant clinical findings
D7230	Surgical removal impacted tooth – partially bony
D7240	Surgical removal impacted tooth – complete bony
D7241	Surgical removal impacted tooth – complete bony with unusual surgical complications	Diagnosis, current periapical or panoramic radiograph, and relevant clinical findings to explain the unusual complications

*This list is not comprehensive.

PacificSource Criteria for Coverage of Periodontal Scaling and Root Planing

In response to questions from providers, we’d like to take a moment to outline our criteria for periodontal scaling and root planing (claim codes D4341 and D4342), along with the reasoning behind them. Please know that our prior authorization process and careful claims review are part of our goal of ensuring affordable, quality care for our dental members.

In developing our criteria, we began with the 2011-2012 edition of The ADA Code on Dental Procedures and Nomenclature (CDT), which defines periodontal scaling and root planing as “…instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms.”

With that definition in mind, when reviewing D4341 or D4342 claims, we consider the following clinical information: 

• Evidence of periodontal disease. Probing depths alone are not the single determining factor for this diagnosis; clinical studies have shown that periodontal probing is imprecise and may not be an indicator of periodontal disease. Even a five or six millimeter pocket may simply represent swollen gingival tissue caused by inflammation.
• Evidence of attachment and bone loss with exposed root surfaces and the presence of root surface calculus. We require diagnostic radiographs to show the alveolar bone height and contour in interproximal areas. When available, we prefer current full mouth or vertical bitewing radiographs. Panoramic radiographs are normally not adequate for evaluation of bone loss.
• Periodontal chart notes or a narrative listing other relevant clinical findings, including the presence of medical conditions that may compromise or be compromised by the patient’s periodontal health.

Typically, local anesthetic is required for scaling and root planing, and the procedure is arduous and time consuming. Completion of four quadrants of scaling and root planing in one appointment is extremely difficult for the patient and the provider. In rare cases when treatment is completed in one appointment, please submit a narrative explaining the extenuating circumstances that made it necessary.

We recommend that you request prior authorization if there is a question about the patient qualifying for the scaling and root planing benefit. If you have any questions not addressed in this article, you are welcome to contact us at (866) 373-7053 or dental@pacificsource.com.

New Voluntary Dental Plan an Affordable Option

In our current economy, many employers are struggling with their ability to offer benefit packages that include dental. Our new Voluntary Dental plan makes it easy for employers in Oregon with 26 or more employees to continue to offer dental to employees without increasing their organization’s healthcare costs.
With Voluntary Dental, employees are responsible for the full premium, but they get the convenience that comes with an employer-sponsored plan, and richer benefits than they might otherwise be able to afford through individual coverage.

Employers benefit by being able to offer employees a more complete benefit package that includes dental. They can choose from 12 different Dental Advantage plans. Key features of the plan:

• Members can lower their out-of-pocket costs by using an Advantage Dental Network provider. 
• In most cases, there is a 12-month waiting period for Class II Complicated and Class III services. 
• An Orthodontia rider is available. 
• The dental plan can be sold as dental-only or combined with a PacificSource medical plan.

As a dental provider you are likely aware that poor oral hygiene has a high correlation with the occurrence of heart disease and diabetes, and can increase the risk of premature birth in pregnant women. With this new dental plan we hope to increase the number of PacificSource dental members, improving not only oral health, but overall health as well.

The Advantage Dental and PacificSource Partnership: What’s In It for You

In July of 2010, PacificSource Health Plans acquired Advantage Dental’s 35,000 commercial plan members and made Advantage its exclusive dental network. As a dental provider, it is advantageous for you and your practice to sign up with the Advantage Dental Network of providers for several reasons:

• Becoming a part of the network will give you access to new patients insured by PacificSource and the Healthy KidsConnect Plan in addition to potential patients through the Oregon Health Plan.
• Advantage is collaborating with PacificSource to work on improved overall health outcomes.
• Advantage offers all of its contracted providers special discounted pricing on products from all the major dental supply companies, including: Henry Schein, Dentsply, Tusla, and Patterson.
• Advantage offers additional services for network dentists, such as consulting, patient financing, and HR services.
• Advantage is owned and managed by dentists and works to ensure dentists have a voice in the changing future of dentistry.
• Advantage offers ownership for those interested.
• Advantage offers participation in a statewide call program for emergency, urgent, and after-hours dental care.

PacificSource Performance at a Glance - October 2011

Dental Claims Processing	Actual	Target
Turnaround Time (days):	11.28	10
Accuracy:	99.20%	99%
Provider Service	Actual	Target
Reporting deadlines met:	99%	100%
Cap & admin payment deadlines met	99%	100%
Claims in research queue over 14 days:	0%	16%
Provider Satisfaction:	95%	95%

Questions? We're Happy to Help

Contact PacificSource Dental Customer Service for Questions Concerning:

• Member benefits or eligibility
• Status of a specific claim or EOP

Email: dental@pacificsource.com

Phone: 541.225.1981 (Eugene) or 866.373.7053 (all other areas)

Fax: 541.225.3655

Contact Advantage Provider Relations for Questions Concerning:

• Becoming a contracted provider
• Provider contracts

Email: providerrelations@advantagedental.com

Phone: 866.268.9616

Website: www.AdvantageDental.com

Fax: 866.268.9318