Specialty Referral for Periodontics

Primary Care Dentists (PCD) are expected to administer all phases of periodontal treatments with the exception of periodontal surgeries. Before a referral can be authorized, a complete periodontal work-up must be completed by the PCD through a non-surgical approach. After healing is completed, if the PCD determines that oral hygiene is acceptable and pocket depths are unmaintainable, a referral can be requested from Access. Surgeries must be done by a panel provider after authorization is received from Access. When requesting a periodontist referral, the PCD must submit the following documentation:

· Case history.
· Areas or tooth numbers where surgery is required.
· Pre-scaling pocket depth charting.
· FMX.
· A copy of the patient chart indicating the dates on which periodontal services were rendered.
· Documentation indicating the dates the PCD provided full mouth root planing for the member.
· A post-scaling (3-6 months after initial root planing) pocket depth charting.
· The PCD is responsible for providing the following treatments: root planing, diagnosis, x-rays, pocket depth charting, curettage, occlusal adjustment, prophylaxis, oral hygiene instructions and emergency abscess treatments.
· Grafting, splinting and treatments on teeth with a poor periodontal prognosis are not benefits under Access Dental Plan.

Specialty Referral for Endodontics

Performing endodontic treatments on all teeth, including molar teeth is the responsibility of the PCD. Referral to an endodontist without prior authorization from Access, is the financial responsibility of the PCD.

The PCD is responsible for providing all palliative emergency treatments on teeth, even teeth that might need treatment from an endodontist due to a complication. If, for any reason, the PCD determines that the palliative treatment must be done by an endodontist, the PCD must obtain an emergency treatment authorization from Access. The PCD must thoroughly document the patient chart regarding the condition and why therapy cannot be done at the PCD's office.

For Access Dental Plan to bear financial responsibility for the endodontic treatment, the following must exist:

The tooth must be critically important to the integrity of the oral condition of the patient.
Specific reasons must exist for making the treatments by the PCD contradictory (i.e. failure of an existing root canal, calcified canals indicated through radiographs depicting an endodontic file in the blocked canal, broken instruments and periapical pathology remaining after standard therapy.)

The following documents must be submitted with a referral request for referral to an endodontist:
· Reason why the treatment cannot be performed at the PCD's office.
· FMX or bilateral bite wings.
· All working x-rays with rubber dam and files in place demonstrating complications such as calcification of the canals preventing proper access for instrumentation.
· Prognosis of the tooth.
· Documentation of the complication in the chart.
· Date of the previous root canal, if applicable.
· Symptoms.

Inadequate access to perform the procedure or lack of proper instruments to perform the procedure are not acceptable reasons for referral to an endodontist. All requests for referral to an endodontist are reviewed by the Dental Consultant to determine whether the financial responsibility lies with Access Dental Plan or with the PCD.

Specialty Referral for Oral Surgery
Oral surgery services are expected to be delivered by the PCD with exceptions for partial bony, full bony extractions, biopsies or any surgery on a patient whose physician will not allow the PCD to perform the procedure at the PCD's office (documentation from the physician is required.)
Requests for referral to an oral surgeon must be accompanied by a diagnostic x-ray completely depicting the apical area of the tooth. If the x-ray is non-diagnostic, the x-ray charges from the specialist office will be charged back to the PCD's office.

Access will cover extractions of impacted teeth only with an existing pathology. Extraction of immature, erupting third molars, which are currently impacted (usually on patients 18 years of age or younger) is not a covered benefit. Extraction of impacted, asymptomatic teeth with no pathology on adult patients is not a covered benefit. Oral surgery procedures related to orthodontic treatments are not covered benefits under the Healthy Families Program.

Specialty Referral for Pedodontics
PCDs are responsible for providing all necessary pedodontic care to their assigned enrollees, so long as that care is within their clinical competency. If the PCD is unable to provide appropriate pedodontic care because of the age of the patient or the complexity of treatment required, or because of the existence of significant management or behavioral problems, the PCD may request that the patient be referred to a pedodontist. Cases of rampant caries or baby bottle syndrome are not reasons for referral unless the patient is demonstrating significant behavioral problems that the PCD cannot handle. A complete narrative description of the case must be submitted to Access with the referral request. Documentation of one attempt at treatment by the PCD must be submitted with the referral request. Pedodontic referrals are not available to children 11 years old and older under the LAPHP and GMC programs. Access will be financially responsible for all approved pedodontic referrals.