Gateway HealthSM Gateway to Practitioner Excellence® Pay-for-Performance Program
The Gateway HealthSM Gateway to Practitioner Excellence® pay-for-performance program is a quality incentive program that rewards United Concordia Dental participating dentists for providing prophylactic dental services (D1110, D1120) to Gateway HealthSM Medical Assistance members between the ages of 2-21. New for 2014 is a dental directory link that PCPs can use to refer members to the dentist.
For more information about the Gateway HealthSM 2014 GPE® Program, go to http://www.gatewayhealthplan.com/providers/gateway-practitioner-excellence
Benefit Limit Exceptions for Pennsylvania Medical Assistance Recipients
A benefit limit exception assures consistent coverage determinations for members age 21 years and older who have a full benefit package. This does not apply to members under the age of 21 or members residing in a nursing home or an intermediate care facility.
A BLE request may be submitted for one of the following dental services:
- Additional oral evaluations (D0120) above the one per 180 day limit
- Additional prophylaxis (D1110) above the one per 180 day limit
- Additional dentures above the lifetime limit of one per upper arch, full or partial, regardless of procedure code (D5110, D5130, D5211, D5213) and one per lower arch, full or partial, regardless of procedure code (D5120, D5140, D5212, D5214)
- Crowns and adjunctive services (D2710, D2721, D2740, D2751, D2791, D2910, D2915, D2920, D2952, D2954, D2980)
- Periodontic services (D4210, D4341, D4355, D4910)
- Endodontic services (D3310, D3320, D3330, D3410, D3421, D3425, D3426)
A BLE request may be submitted on a prospective (pre-authorization) or retrospective (claim) basis, but retrospective requests must be received no later than 60 days from the date of the claim rejection. A request is made by submitting a completed ADA claim with an attached Dental Benefit Limit Exception Request Form to the address below.
Click here to access the Dental Benefit Limit Exception Request Form.
|Gateway HealthSM: Pre-Authorizations |
PO Box 2170
Milwaukee, WI 53201
|Gateway HealthSM: Claims |
PO Box 2190
Milwaukee, WI 53201
Each field of the Dental Benefit Limit Exception Request Form must be completed, including the Benefit Exception Request Type, Benefit Limit Criteria to be reviewed, and a narrative explaining why the patient meets the criteria for a benefit limit exception. Documentation supporting the need for the service must be provided, including but not limited to chart documentation, diagnostic study results, radiographs (if applicable), medical and dental history.
Written notification of the decision for a prospective BLE request will be issued as expeditiously as the member’s health care condition requires, but no later than 21 calendar days from the date of receipt.
Written notification of the decision for a retrospective BLE request will be issued within 30 calendar days from the date of receipt.
If you have any questions about dental benefit limit exception requests, please call Dental Customer Service at 1-866-568-5467.