DentaCom
What system do we use to check a member's eligibility?
CED, I2/I4
Is there any timely filing for DPPO claims?
INN - No timely filing
OON- 365 Days
If line # 36 is signed on a claim form and line # 37 is blank, who do we pay?
The customer/member
In your own words explain COMP MOLARS OK
White fillings done on molar teeth WILL NOT downgrade
What is the turn around time if you mail something to the member?
15 Business Days
What system do we use to look at a member's preventive history on file?
If we are looking in i6, which key would we press to look at payment information?
F8
If a procedure denies and the reason code starts with the letter F what does that denial indicate?
The procedure denied due to frequency
What will it say in p1 if crowns DO NOT downgrade?
NO LESSER BENEFIT OR DO NOT LD
What system do we use to send out a list of providers?
Eservices
What keys do we press to go from CED to DentaCom?
If the claim form states payment - Y who would Cigna issue payment to?
The Provider
If a core build up denies as inclusive (PB) because they billed on the same date as the crown, what information do we need to reprocess the core build up?
Prep and Seat Date
Explain NO INT COB
If both individuals work for the same company we will not coordinate benefits
What type of claims can SDA process over the phone?
BA (Simple) Claims
IH screen
If Cigna is secondary, what information would need from the primary insurance in order to process?
An EOB from the primary insurance
For an ortho claim what three pieces of information do we need to process out the claim?
Band Date, Months in Treatment and Total Case Fee
When the ortho max carries over from the prior insurance
What is the turnaround time to process an appeal?
60 calendar days
When using p8, if the FREQ section shows
12 2 3, what is the frequency of that code?
2 per policy year
If there is a claim for Scaling and Root planing (D4341) that is pending for more additional information, what might we be looking for?
Perio charting
For Prosthetics what 4 pieces of information do we require?
Full Mouth/Pano Xray, List of Missing Teeth, Date and reason of prior placement and prep and seat date
If p1 states NO ALT BENE provision how would you explain that to the caller?
Advise that fillings and crowns both DO NOT downgrade on the plan.
Plan COB is Maintenance of benefits, Cigna would pay $500 and the other insurance paid $550. What would we pay out as secondary?
Answer $0