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