Delta Dental to Correct System Processing of Core Buildups
Delta Dental of California has confirmed to CDA that it will modify the process in which core buildup procedures are adjudicated.
Core buildups (D2950 and D6973) have historically been considered non-benefits “unless an exceptional buildup can be demonstrated by written remarks and x-rays.” In other words, core buildups have been considered part of a crown prepration unless there is insufficient remaining tooth structure to support a crown.
In September 2009, Delta Dental established a new policy regarding x-ray submission that included a statement that a core buildup does not require an x-ray and/or written report and reaffirmed the policy that core buildups are typcially part of the crown preparation, “except when need is suggested by dental history such as following root canal treatment.” Buildups to remove undercuts, fill irregularities or add bulk to the preparation are included in the fee for crown or bridge retainer and are not eligible for core buildup payment.
In an effort to streamline processing, buildups were set up to be automatically allowed based upon dental history. If the buildup procedure was not automatically allowed, an allowance would be made for a buildup as a separate procedure upon reevaluation by a dental consultant.
Delta Dental has acknowledged since the elimination of the requirement to send x-rays and the change in the core buildup processing there has occurred in some cases, a delay in payment of buildup procedures that qualify as a separate benefit due to the cumbersome reevaluation process. In response to members’ concerns, CDA has been working with dentists and Delta to have individual claim denials for core buildups reprocessed and paid. As part of those discussions, Delta Dental recognized the need to fix its processing flow in order to modify the review process so that a buildup procedure will be reviewed by a dental consultant to determine whether the tooth meets the criterion for payment of a buildup as a separate procedure. In the future, claims with a history of root canal, 3+ surface restorations, or a history of crown will be auto- processed. If a core buildup is billed and does not meet these criteria, it will be sent to a Dental Consultant for review and coverage determination. Additionally, the policy regarding x-ray submissions will revert to the previous policy. X-rays and/or written report are required for core-build ups.
Previously denied claims for core buildups, which comply with the policy of history of root canal or where insufficient tooth structure remains, can be resubmitted to Delta for reconsideration on a case-by-case basis. These claims should include an appeal cover sheet Delta Dental Provider Dispute Form; otherwise, the claim may be denied as a duplicate claim.