PSGPROV_2020_184_S

CARTA CIRCULAR #M2011258

20 de noviembre de 2020

A TODOS LOS PROSTODONCISTAS PARTICIPANTES DE TRIPLE- S SALUD, INC.

(PLAN VITAL)

Re: Carta Circular 20-1028: Actualización Tarifario Dental CY 2020-2021

Reciba un saludo cordial de parte de Triple-S Salud, Inc. (Triple-S). Como es de su

conocimiento, el 28 de octubre de 2020, la Administración de Seguros de Salud (ASES) emitió

la Carta Normativa 20-1028 mediante la cual anunció la actualización del tarifario dental. Por

tal razón, le informamos las tarifas y nuevos códigos para los servicios prestados a partir del

1ro de julio de 2020.

CÓDIGO DESCRIPCIÓN TARIFA

D0120 Periodic oral evaluation - established patient $15.42

D0140 Limited oral evaluation - problem focused $20.78

D0150 Oral evaluation $24.41

D0210 Intraoral - complete series of radiographic images $49.76

D0220 Intraoral - periapical first radiographic image $ 8.60

D0230 Intraoral - periapical each additional radiographic image $ 8.68

D0270 Bitewing - single radiographic image $ 8.62

D0272 Bitewing - two radiographic images $15.01

D0330 Panoramic radiographic image $30.86

D1110 Prophylaxis - adult $27.85

D2140 Amalgam - one surface, primary or permanent $39.67

D2150 Amalgam-two surfaces, primary or permanent $48.78

D2160 Amalgam - three surfaces, primary or permanent $58.35

D2161 Amalgam - four or more surfaces, primary or permanent $68.90

D2330 Resin - based composite - one surface, anterior $44.22

D2331 Resin - based composite - two surfaces, anterior $54.26

D2332 Resin - based composite - three surfaces, anterior $65.00

D2335 Resin - based composite - four or more surfaces, anterior $78.29

D2391 Resin - based composite - one surface, posterior $48.18

D2930 Prefabricated stainless-steel crown, primary tooth $62.83

D2940 Protective restoration $31.25

D3120 Pulp cap - indirect (excluding final restoration) $22.44

PSGPROV_2020_184_S

CÓDIGO DESCRIPCIÓN TARIFA

D3221 Pulpal debridement, primary and permanent teeth $ 27.29

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $150.70

D3320 Endodontic therapy, premolar tooth (excluding final restoration) $164.04

D7140 Extraction, erupted tooth or exposed root $ 43.86

D7210 Surgical removal of erupted tooth $ 79.86

D7220 Removal of impacted tooth - soft tissue $127.60

D7230 Removal of impacted tooth - partially bony $156.74

D7240 Removal of impacted tooth - completely bony $180.44

D7250 Surgical removal of residual tooth roots $ 56.80

D7510 Incision and drainage of abscess-intraoral soft tissue $ 23.37

D9110 Palliative (emergency) treatment of dental pain - minor procedure $ 26.25

Si usted ha sometido reclamaciones con estos códigos para servicios prestados a partir del

1ro de julio de 2020, no será necesario solicitar un ajuste ya que serán procesadas

automáticamente.

De tener alguna duda o pregunta, puede comunicarse con el Centro de Servicio al Proveedor al

1-844-263-6063. Nuestro Centro de Llamadas está disponible de lunes a domingo de 7:00 a.m.

a 7:00 p.m.

Cordialmente,

Benjamin Santiago, MD

Vicepresidente

División de Manejo Médico

Triple-S Salud, Inc.

Anejo

PSGPROV_2020_184_E

CIRCULAR LETTER #M2011258

November 20, 2020

TO ALL IN-NETWORK PROSTHODONTIST OF TRIPLE-S SALUD, INC. (PLAN

VITAL)

Re: Circular Letter 20-1028: CY 2020-2021 Updates Dental Fee Schedule

Best regards from Triple-S Salud, Inc. (Triple-S). As you may know, on October 28, 2020, the

Health Insurance Administration (ASES) issued the Normative Letter 20-1028 to announce the

CY 2020-2021 Updated Dental Fee Schedule. For this reason, we inform you the rates and new

codes for the services rendered as of July 1, 2020.

CODE DESCRIPTION FEE

D0120 Periodic oral evaluation - established patient $15.42

D0140 Limited oral evaluation - problem focused $20.78

D0150 Oral evaluation $24.41

D0210 Intraoral - complete series of radiographic images $49.76

D0220 Intraoral - periapical first radiographic image $ 8.60

D0230 Intraoral - periapical each additional radiographic image $ 8.68

D0270 Bitewing - single radiographic image $ 8.62

D0272 Bitewing - two radiographic images $15.01

D0330 Panoramic radiographic image $30.86

D1110 Prophylaxis - adult $27.85

D1120 Prophylaxis - child $20.00

D1206 Topical application of fluoride varnish $14.91

D1208 Topical application of fluoride - excluding varnish $14.83

D1351 Sealant - per tooth $16.31

D2140 Amalgam - one surface, primary or permanent $39.67

D2150 Amalgam-two surfaces, primary or permanent $48.78

D2160 Amalgam - three surfaces, primary or permanent $58.35

D2161 Amalgam - four or more surfaces, primary or permanent $68.90

D2330 Resin - based composite - one surface, anterior $44.22

D2331 Resin - based composite - two surfaces, anterior $54.26

D2332 Resin - based composite - three surfaces, anterior $65.00

D2335 Resin - based composite - four or more surfaces, anterior $78.29

D2391 Resin - based composite - one surface, posterior $48.18

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CODE DESCRIPTION FEE

D2930 Prefabricated stainless-steel crown, primary tooth $ 62.83

D2940 Protective restoration $ 31.25

D3120 Pulp cap - indirect (excluding final restoration) $ 22.44

D3220 Therapeutic pulpotomy (excluding final restoration) $ 54.34

D3221 Pulpal debridement, primary and permanent teeth $ 27.29

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $150.70

D3320 Endodontic therapy, premolar tooth (excluding final restoration) $164.04

D7140 Extraction, erupted tooth or exposed root $ 43.86

D7210 Surgical removal of erupted tooth $ 79.86

D7220 Removal of impacted tooth - soft tissue $127.60

D7230 Removal of impacted tooth - partially bony $156.74

D7240 Removal of impacted tooth - completely bony $180.44

D7250 Surgical removal of residual tooth roots $ 56.80

D7510 Incision and drainage of abscess-intraoral soft tissue $ 23.37

D9110 Palliative (emergency) treatment of dental pain - minor procedure $ 26.25

If you have submitted claims with these codes for services rendered as of July 1, 2020, it will

not be necessary to request an adjustment as they will be processed automatically.

Should you have any question, contact our Provider Service Center at 1-844-263-6063. Our call

center is available from Monday to Sunday from 7:00 a.m. a 7:00 p.m.

Cordially,

Benjamin Santiago, MD

Vice President

Medical Management Division

Triple-S Salud, Inc.

Enclosure

Autorizado por la Comisión Estatal de Elecciones CEE-SA-19-166

Circular Letter 20-1028 October 28, 2020 To: Managed Care Organizations (MCOs) contracted to offer services under the

Government Health Plan Program (Plan Vital); Dentists; Primary Medical Groups (PMG) and Participants Providers

Re: CY 2020 - 2021 Updated Dental Fee Schedule On October 20,2020 the Puerto Rico Health Insurance Administration (ASES, for its Spanish acronym) issued the Circular Letter 20-1020, therefore ASES the didn’t include in the attachment the CDT codes D2940 and D1999 to be used for the COVID fee of $14.51. Enclosed the CY 2020 - 2021 Updated Dental Fee Schedule for implementation effective July 01, 2020. All MCOs must distribute this Circular Letter to all participating Vital Plan providers. In addition, they are required to modify the payment systems for the processing and payment of the invoices issued by the reference codes. Cordially, Jorge E. Galva, JD, MHA Executive Director Attachment

Attachment

Autorizado por la Comisión Estatal de Elecciones CEE-SA-19-166

HCPCS Description Type

Contract Year 2020-2021 Fee

ScheduleD0120 Periodic oral evaluation - established patient I-Oral Evaluations $15.42D0140 Limited oral evaluation - problem focused I-Oral Evaluations $20.78D0150 Comprehensive oral evaluation - new or established patient I-Oral Evaluations $24.41D0160 Detailed and extensive oral evaluation - problem focused, by report I-Oral Evaluations $40.03D0210 Intraoral - complete series of radiographic images I-X-Rays $49.76D0220 Intraoral - periapical first radiographic image I-X-Rays $8.60D0230 Intraoral - periapical each additional radiographic image I-X-Rays $8.68D0270 Bitewing - single radiographic image I-X-Rays $8.62D0272 Bitewings - two radiographic images I-X-Rays $15.01D0330 Panoramic radiographic image I-X-Rays $30.86D1110 Prophylaxis - adult I-Prophylaxis $27.85D1120 Prophylaxis - child I-Prophylaxis $20.00D1206 Topical application of fluoride varnish I-Fluoride $14.91D1208 Topical application of fluoride - excluding varnish I-Fluoride $14.83D1351 Sealant - per tooth I-Sealants $16.31D2140 Amalgam - one surface, primary or permanent II-Restorations $39.67D2150 Amalgam - two surfaces, primary or permanent II-Restorations $48.78D2160 Amalgam - three surfaces, primary or permanent II-Restorations $58.35D2161 Amalgam - four or more surfaces, primary or permanent II-Restorations $68.90D2330 Resin-based composite - one surface, anterior II-Restorations $44.22D2331 Resin-based composite - two surfaces, anterior II-Restorations $54.26D2332 Resin-based composite - three surfaces, anterior II-Restorations $65.00D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) II-Restorations $78.29D2391 Resin-based composite - one surface, posterior II-Restorations $48.18D2930 Prefabricated stainless steel crown - primary tooth III-Inlays/Onlays/Crowns $62.83D2940 Protective restoration II-Restorations $31.25D3120 Pulp cap - indirect (excluding final restoration) II-Endodontics $22.44D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament II-Endodontics $54.34D3221 Pulpal debridement, primary and permanent teeth II-Endodontics $27.29D3310 Endodontic therapy, anterior tooth (excluding final restoration) II-Endodontics $150.70D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) II-Endodontics $164.04D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) II-Simple Extractions $43.86D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated II-Surgical Extractions $79.86D7220 Removal of impacted tooth - soft tissue II-Surgical Extractions $127.60D7230 Removal of impacted tooth - partially bony II-Surgical Extractions $156.74D7240 Removal of impacted tooth - completely bony II-Surgical Extractions $180.44D7250 Removal of residual tooth roots (cutting procedure) II-Surgical Extractions $56.80D7510 Incision and drainage of abscess - intraoral soft tissue II-Oral Surgery $23.37D9110 Palliative (emergency) treatment of dental pain - minor procedure II-Emergency (Palliative) $26.25D9223 Deep sedation/general anesthesia - each 15 minute increment II-Anesthesia $185.99D1999 COVID Fee Temporary Code $14.51