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AAPD CDBP voices Concern to United Concordia Companies On Radiograph Policy Change

March 2013 Volume XLVIX Number 2

When it comes to advocating for members, the AAPD Council on Dental Benefit Programs work tirelessly to achieve a positive result.

 

CDBP staff and council members became aware in November that United Concordia Companies Inc. is changing its periapical radiograph policy in Washington, Ore., Idaho and Montana effective Jan. 1, 2013. Originally, the carrier planned to deny all periapical radiographs taken concurrently with a periodic evaluation.

The initial communication from UCCI stated that periapicals taken in conjunction with a periodic exam would be automatically denied. Dentists would have to file an appeal after receiving the denial from UCCI.

The point of agreement between UCCI and the AAPD is that periapical radiographs should not be taken routinely during a periodic evaluation.

While the FDA guidelines accepted by the ADA and American Academy of Pediatric Dentistry do not include routine periapicals with a periodic evaluation, there can be  many legitimate reasons for taking them as described in the new communication. Some of these legitimate reasons why a dentist needs to take a periapical on the same day as a periodic exam, such as when a patient has a specific complaint that must be investigated, the dentist notices something abnormal that requires a radiograph to complete the diagnosis or there is a need to monitor growth and development. CDBP staff began a dialogue with UCCI executives, voicing concern that dentists would be required to file an appeal to be paid, even when proper justification was submitted.

Beginning Jan. 1, for periapical radiographs taken with a periodic evaluation, UCCI will begin requiring dentists to submit both justification and a copy of the radiograph.

CDBP sees the rationale for the justification, but not to submitting a copy of the radiograph.

The issue is the reason for taking the radiograph, not what is subsequently seen on the radiograph. For this reason, CDBP is still unable to understand the rationale for requesting a copy of the radiographs. The procedure in question is the taking of the radiographs, not any subsequent procedure or diagnosis. This is the only issue when deviating from the guidelines. Review of the radiographs will not provide more information about the reason for taking the radiographs than will the written justification, and its an unnecessary burden when the doctors are already being asked to do a completely new thing. What if there is an absolutely legitimate reason for taking the radiographs, but they serve to rule out a problem? There will be nothing to note on the radiograph.

"The success we had with the UCCI payment policy is that the claim will be paid on initial submission if  justification is submitted with the claim," AAPD Dental Benefits Manager Mary Essling said. "There is no disagreement that routine periapical radiographs with a periodic evaluation will be denied."

"Although the outcome is not entirely what we had hoped, this is a good example of CDBP going to bat for ADA members," Essling said.

Many times throughout the year, CDBP staff will contact dental benefit plan car riers to discuss issues that affect member dentists and/or the public. While contractual issues and plan design may limit the desired changes, most carriers are open to discussion.