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Dental Provider Manual
The following information is for our Dental Provider Community.
To quickly access the information you need, click and print the individual section PDF. You can also download and print the complete manual.
Note: Per the terms of the Participation Agreement, providers are required to adhere to all policies and procedures contained in the manual below, as applicable. Any changes will also be communicated through BlueImpressions, our dental administrative newsletter.
Chapter 1: Welcome to CareFirst
| Chapter 1: Welcome to CareFirst | |
| Introduction to CareFirst | |
| Online Resources and Contact Information | |
| Introduction to the Manual | |
| How to Use this Manual | |
| New Providers/Office Staff Begin Here |
Chapter 2: Product Descriptions
| Chapter 2: Product Descriptions | |
| Overview | |
| Dental Traditional (Indemnity) | |
| Dental Preferred Provider Organization | |
| Dental Exclusive Provider Organization | |
| Dental Health Maintenance Organization | |
| Federal Employees Health Benefit Plan/Federal Employee Program | |
| National Dental GRID | |
| Third Party Administrators (TPA) |
Chapter 3: Provider Network Requirements: Administrative Functions
| Chapter 3: Provider Network Requirements: Administrative Functions | |
| Credentialing | |
|
Role of the PGD – BlueChoice and The Dental Network DHMO |
|
| Reduction, Suspension or Termination of Privileges | |
| Quality of Care Termination | |
| All Other Sanctions or Terminations | |
| Member to be Held Harmless | |
| Reimbursement | |
| Confidentiality | |
| Administrative Service Policy | |
| Treatment of Family Members | |
| Member Complaints | |
| Requests for Charts |
Chapter 4: Claims, Billing and Payments
| Chapter 4: Claims, Billing and Payments | |
| Introduction to Claims Submission | |
| Provider Self Service | |
| Basic Claim Submission Requirements | |
| Electronic Capabilities | |
| Paper Claims Submission Process | |
| Pre-Treatment Estimate Submission Process | |
| Notice of Payment | |
| Claims Overpayments | |
| Effective Follow-Up on Claims | |
| Corrected Claims, Inquiries and Appeals | |
| Coordination with Other Payers/Other Party Liability |
Chapter 5: Fraud, Waste and Abuse
| Chapter 5: Fraud, Waste and Abuse | |
| Special Investigations Unit | |
| Payment Integrity Program |
Chapter 6: Care Management
| Chapter 6: Care Management | |
| Quality Improvement Program | |
| Clinical Guidelines | |
| Performance Data | |
| Population Assessments | |
| Maintaining the Access, Availability and Quality of Our Network Providers | |
| Population Health and Social Determinants of Health | |
| Complaint Process | |
| Language Assistance | |
| Clinical Programs | |
| Clinical Resources | |
| Inpatient Hospitalization Services |
Chapter 7: Policies and Procedures
| Chapter 7: Policies and Procedures | |
| Medical Policy and Technology Assessment | |
| Dental Clinical Criteria | |
| Dental Claims Adjudication Edits | |
| Basic Claim Adjudication Policy Concepts | |
| General and Specialty Related Claim Adjudication Policies and Reimbursement Guidelines | |
| Radiology/Imaging |
Chapter 8: Medicare Advantage
| Chapter 8: Medicare Advantage | |
| Provider Network Overview | |
| Participating Provider Responsibilities | |
| Product Information | |
| Claims Submission | |
| Appeals and Grievances | |
| Medicare Pharmacy Management | |
| Pre-Treatment Estimate Submission Process |