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QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa Dental Guidelines | Dental Guidelines 1 2.pdf |
Dental Guidelines Select the correct category (Dental Category) and tooth number (for applicable services) to prevent unnecessary denials. Services evaluation andapproval based onthe Core privileges (for General Dentist) &Non-core privileges (forcertified specialists) only asper QCHP guidelines. Services validation andapproval asper TOB ofpolicy such as crowns, prosthesis, polishing,implants, ortho treatment..etc. Periodicity for scaling /cleaning/polishing is based on the TOB of the policy. Filling services are approved with respective individual tooth number, multi quantity insingle service linenotacceptable (in both Pre-Approval/Registration and MDS ) inclaims submission. Upcoding such asusing adult treatment codes /tariff for PEDO treatment may result inpartial payment ofthesubmitted claims. Unbundling of services will not be considered such as Pulpotomy and filling billed for same tooth etc. Dental implants are covered only if mentioned in the TOB. Partial Denture isoneservice code for1 to7 teeth inno, as peragreed tariff. Orthodontic andalldental services periodicity consider the service date during theclaim submission. Orthodontic treatment is covered for the age of 12yrs to 25yrs or as mentioned in the TOB of the policy for the IOTN 4 and IOTN 5. www. qlm. com. qa 2 | Dental Guidelines 1 2.pdf |
Dental Guidelines Myofunctional Appliances coverable only Ifthepolicy mentions orthodontic treatment covered irrespective Iiof age or interceptive orthodontic treatment covered. Transparent & ceramic brackets and Invisalign or clear Aligners are not covered unless mentioned in the TOB of the policy. Cosmetic and Congenital services are not covered unless mentioned in the TOB of the policy. Habit breaking /space maintainers appliance coverage asperpolicy TOB, (ifpolicy covers preventive and interceptive orthodontic treatment ). Flexite /flexible dentures, broken /lost retainers, temporary fillings /temporary crown,micro implants,Desensitizing and laser procedure are not covered. Implant services must accompany a detailed dental report including the stages of services of implant and Operative notes along with supportive radiograph to be provided during claim submission. Gum treatments must accompany a detailed medical report by the treating physician clarifying the complain and type of Gum treatment done with teeth/ quadrant. Gum /Periodontal Treatment for more than 3 teeth requires detailed medical report, operative notes, pre- OPG and Periodontal chart-all sign and stamped by the treating Doctor. Gingivectomy for more than 2 teeth must accompany adetailed dental report, operative notes, pre and post treatment photos of the arch alone. Root Planning/ curettage services must accompany adetailed dental report,complete claim form,periodontal chart, and operative notes along with supportive radiograph to be provided during claim submission. www. qlm. com. qa 3 | Dental Guidelines 1 2.pdf |
Dental Guidelines Bone grafts andflap surgeries must accompany a detailed dental report,pre-service x-ray, periodontal chart, andoperative notes. Surgical and complicated extraction must accompany adetailed operative note and pre-service x ray. Orthodontics claims require Cephalogram, OPG, photos, Orthodontic assessment report based on cephalogram analysis, IOTN grade, treatment plan and visit record with patient signature. Please check thetable of Radiology requirement,page No 5 Post-procedural x-rays are part and parcel of dental treatment. Photos should cover only the working area not the member's face. Services involving multiple steps for the outcome of final treatment are considered as Part and Parcel services of the Final treatment and will not be billed to the QLM member. Part and parcel services mean that cannot be performed separately and shouldn't be billed to the member. Unagreed service to be updated before claims submission, failure to do so will result in claim denials. www. qlm. com. qa 4 | Dental Guidelines 1 2.pdf |
Service Description Pre-Service Post-Service Accepted Radiology Method Root Canal Treatment Yes Yes IOPA Complicated Extraction/Surgical extraction/Impacted /Embedded molars /Cysts of jaw Yes No IOPA or OPG Multiple restorations above 3 At a time, Interproximal caries, large carious lesions. No Yes OPG or IOPA Implants Yes Yes OPG Orthodontic treatment Yes No OPG, Cephalogram and photos Gum and periodontal treatments like Flap surgeries, Gingivoplasty, bone graft Yes No OPG TMJ disturbances Yes No OPG Crowns Yes Yes OPG or IOPA as per number of teeth involved Bridges Yes Yes OPG Dentures / prosthesis Yes Photo OPG or photo Radiology Requirement vs Procedure 5 | Dental Guidelines 1 2.pdf |
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