cigna dental care...4 benefits for network dentists source of patients by participating in the cigna...

Visit our useful web sitewhere you’ll find:

◗ Information to help members

◗ Power PurchasingProgram Catalog

◗ Dental office supplyrequisition form

◗ An opportunity to e-mail uswith questions or comments

◗ And more.

CIGNA Dental Care

DENTAL OFFICEREFERENCE GUIDE

Please note your dental officenumber here for easy reference.

cigna.com

DIAL

1.800.DIAL.CDHTO:

◗ Add an associate

◗ Add or change an office location

◗ Discuss policies and guidelines

◗ Obtain an updated specialist list

◗ Inquire about referral status

◗ Verify patient charges and eligibility

◗ Ask questions about monthly reports

◗ Inquire about supplemental payments

◗ Speak to a CIGNA DentalNetwork Manager

(1.800.342.5234)

CIGNA Dental CareQuickReference

Guide

QuickCIGNA Dental Care

ReferenceGuide

Working Together.

Bet ter.

Eas ier.

Smar ter.

1

Table ofContents

PAGE

2 Welcome3 Who is CIGNA Dental?3 CIGNA Dental Philosophy3 Product Description

4 Benefits for Network Dentists4 Source of Patients4 Compensation5 Power Purchasing Program5 Direct Deposit6 Electronic Filing of Encounter Data6 Supplies

8 Member Information8 Patient Eligibility8 Patient Charge Schedules9 Member’s Financial Responsibility9 Member Education

11 Administrative Procedures11 Patient Encounter Data12 How to Submit Encounter Data13 Where to Send Encounter Data13 Encounter Error Report16 Monthly Reports

25 Specialty Referral Guidelines25 Referral to a Network Specialist26 Referral Process for Both Emergency

and Non-Emergency Conditions27 Authorization Limitations27 Referral to a Network Endodontist27 Referral to a Network Periodontist28 Referral to a Network Oral Surgeon29 Referral to a Network Pediatric Dentist30 Referral to a Network Orthodontist

31 Professional Guidelines and Quality Review31 Professional Standards31 The Dental Facility33 Medical Emergency Preparedness34 The Patient Record/File34 Quality of Patient Care34 On-Site Review

2

Welcome to the CIGNA Dental Care network! We look forward

to a long, successful relationship in our alliance to provide access

to quality dental care services to our members.

The purpose of the CIGNA Dental Care Quick Reference

Guide is to familiarize you and your staff with the CIGNA Dental

Care plan and to acquaint you with the benefits of being a

CIGNA Dental Care network dentist. This guide will help you

understand CIGNA Dental’s expectations of you as a

participating network dentist (e.g. patient records, how to submit

encounters, and the elements of quality management). This

guide will also tell you what you can expect from us (e.g.

monthly reporting, compensation, and administrative support).

We hope you will find this Quick Reference Guide helpful in

answering your questions. Together, this Quick Reference Guide

and the Policy Manual comprise the CIGNA Dental Health

Procedure Manual referenced in your Network General Dentist

Agreement. In addition, please review your CIGNA Dental

Network General Dentist Agreement for further information.

Please note that certain policies may vary depending on state

regulations.

The dental marketplace is continuously changing. We want

to hear your views on the marketplace and our plan policies.

Contact the Provider Service Organization at CIGNA Dental to

share your thoughts on technology, utilization review and

quality management criteria, or other matters of interest.

Welcome

WELC

OME

3

Who is CIGNADental?CIGNA Dental companies rankamong the country’s largest, mostsuccessful dental benefitscompanies. Nearly three millionmembers are cared for by overnineteen thousand generaldentists and specialists whoparticipate in the CIGNA DentalCare network. Over seven millionmembers and over fifty-fivethousand dentists are part of theCIGNA Dental PPO and overthree million members arecovered by our traditional(indemnity) plan.

CIGNA Dental Health, CIGNADental PPO and ConnecticutGeneral Life Insurance Company(indemnity plan) are all part ofCIGNA HealthCare. With theexperience and stability of theseorganizations, we are confidentthat participating with CIGNADental will grow and enhanceyour practice.

CIGNA DentalPhilosophyOur philosophy stresses theimportance of preventive dentistryand early intervention in thedisease process. We believe thisapproach benefits both the patientand the dentist. We know that asuccessful managed dental careprogram is built on long-termrelationships, mutual rewards, andcommon goals; a commitment tothe practice of good dentistry;respect for your freedom to exercisesound professional judgement; andquality patient care provided in asupportive atmosphere.

Product DescriptionCIGNA Dental Care is a manageddental care plan, commonlyreferred to as a prepaid plan. Wedeliver CIGNA Dental Care dentalbenefits to participants through anetwork of dentists who receivecompensation in a variety ofways including, but not limitedto, fixed monthly payments andpatient charges. Fixed monthlypayments are based on thenumber of members who haveselected your office during anygiven month, whether or not thepatient accesses care. Patientcharges are based on the PatientCharge Schedule chosen by themember’s employer or group.

WELCOME

4

Benefits forNetworkDentists

Source of PatientsBy participating in the CIGNADental Care network you will gain:• The opportunity for increased

patient flow and compensationfrom CIGNA Dental Care membersselecting your office.

• The potential for increased patientreferrals from satisfied CIGNADental Care members.

• The opportunity to market yourpractice to many potential newpatients in your area at no cost to you.

With thousands of companiesoffering CIGNA Dental Care totheir employees, our relationshipswith these companies provide youwith significant opportunities togrow your patient base.

CompensationThe compensation package hasbeen developed to remuneratethe dentist fairly for the time andservices required to provide theappropriate quality dental care.

The compensation packageconsists of the following sourcesof income:• Monthly Payments – You

will receive a monthlypayment for each memberselecting your office, whetheror not he or she accesses care.

• Patient Charges – There is apatient charge (copayment) forcertain procedures based uponthe member’s plan design(Patient Charge Schedule) ineffect on the date of service.These charges are the responsi-bility of the member and arepaid directly to your office atthe time of service.

• Supplemental Payments (ifapplicable) – Due to marketdemand, some plans havebeen designed with lowerpatient charges for certainprocedures. To ensure faircompensation for theseservices, CIGNA Dentalprovides a guaranteedminimum payment fordesignated procedures. Thesupplemental paymentschedule can be foundattached to your NetworkGeneral Dentist Agreement.

BENE

FITS F

ORNE

TWOR

K DE

NTIST

S

55

• Office Visit Fees (notapplicable in all states) – Inrecognition that the office isincurring expenses to meethealth and safety require-ments, CIGNA Dental provides a set fee for eachoffice visit when a memberreceives dental services.CIGNA Dental’s payment ofthis fee is based upon theencounter data submitted bythe dental office. For someplans, this fee is paid by themember as a patient charge.Please refer to the PatientCharge Schedule to determinewhen a member should becharged an office visit.

• Other Charges – Themember’s treatment plan mayrequire procedures that are notcovered. For more detailedinformation please seeMember’s FinancialResponsibility on page 9.

Power PurchasingProgramThe Power Purchasing Program isa unique benefit from CIGNADental. By participating in theCIGNA Dental Care network younow have access to valuablediscounts on products andservices, including continuingeducation opportunities.

For the most current list ofvendors and discounts, visit thePower Purchasing web site atwww.CIGNA.com/provider/tools/dental/power.html.

Direct DepositAs many dentists participating inthe CIGNA Dental Care networkalready know, selecting theDirect Deposit payment optionis a fast efficient, and secure wayto get paid. Your money will bedeposited to your bank accounteach month. There’s no need towait for mail delivery, make atrip to the bank or even wait forthe funds to clear. Your bank willgive you immediate access to thedirectly deposited funds.

HOW DOES IT WORK?Instead of mailing a check,CIGNA Dental electronicallytransfers immediately availablefunds to the bank account youselect. You will receive a detailedremittance advice and yourmonthly reports in the mail.

WHY SHOULD I SIGN UP?• Faster payment – Checks

need to be sorted andmatched with reports, whichdelays mailing. Direct depositpayments will reach youraccount several days sooner,and eliminate the possibilityof lost or misdirected mail.

Continued on next page…

BENEFITS FORNETWORK DENTISTS

6

Direct DepositWHY SHOULD I SIGN UP? (continued)• Enhanced cash flow – Not only

will your payments arrive withcertainty at the beginning ofeach month, there is no need to wait for a check to clear.Funds are immediately avail-able to you.

• Reduced bank fees – If yourfinancial institution charges adeposit fee, it is likely to bemuch lower than the checkprocessing or lockbox fee youare paying to deposit a check.

• Administrative efficiency –Your office personnel willreceive an itemized statementand will not need to make a trip to the bank.

To take advantage of DirectDeposit, please contact CIGNADental at 1.800.DIAL.CDH for aDirect Deposit authorization form. Return the completed form and a voided check whichreflects your business bank account number in the postagepaid envelope provided.

Benefits for Network Dentists (continued)

Electronic Filing ofEncounter DataTo make administration easier foryou, CIGNA Dental is pleased tooffer you the ability to file yourencounter data electronically. Thefollowing clearinghouses offerencounter submission at no chargeto CIGNA Dental Care networkdentists. For more informationplease call:

WebMD – www.webmd.com1.888.416.0673

InfoSoft/Softdent –www.softdent.com1.800.262.8593

CIGNA Dental is always working toincrease your options for electronicfiling. We will provide updates toyour office as additional clearing-houses are added in the future.

SuppliesCIGNA Dental provides chartsand forms to you free of charge. You can order by e-mail,fax, mail or phone. See page 7 for a supplies listing and ordering instructions.

BENE

FITS F

ORNE

TWOR

K DE

NTIST

S

7

Catalog Number Pkg. Qty. Pkgs. Requested Description

12201 (50) Pediatric Dental Chart

12202 (50) Adult Dental Chart

12203 (50) Adult Dental Chart - Page 2

12204 (25) Periodontal Evaluation Chart

12205 (50) Medical Update Label

12350 (50) Comprehensive Treatment Plan

12920 (25) Patient Encounter Envelope

12921 (25) Patient Encounter Envelope - CA (For state of California only)

14420 (50) Specialty Referral Form (Generic)

14430 (50) Orthodontic Specialty Referral Form

14530 (25) Specialty Referral Envelope - Eastern and Central Regions

14570 (25) Specialty Referral Envelope - Western Region

15190 (25) Dissatisfaction Form - CA (For state of California only)

532074 (1) Patient Charge Schedules at a Glance

532075 (100) Patient Encounter Form

532739 (100) Patient Encounter Form - CA (For state of California only)

534933 (50) L.A. Third Prophy Encounter Form - CA (For state of California only)

557784 (1) Quick Reference Specialty Referral Guidelines

569023 (1) Quick Reference Guide (Dental Office Reference Guide)

569032 (1) Policy Manual

Dental Office Supply Requisition

FAX YOUR ORDER TO:

CIGNA Dentalc/o Moore Wallace1.800.632.9234

(For faster, more accurate orders)

OR MAIL TO: CIGNA Dentalc/o Moore Wallace1750 Wallace AvenueSt. Charles, IL 601741.800.342.5234

DENTAL OFFICE #: TELEPHONE #:

D: ( )

Company:

Attention:

Street Address:

City:

State: Zip Code:

Dental

SAVE AND COPY AS NEEDED:

SHIP

TO:

(Pl

ease

do

not

use

P.O

. Bo

x)

8

MemberInformation

Patient EligibilityIt is important to verify eligibilitybefore treatment is rendered.Member eligibility can be verified by:• using the CIGNA Dental

Automated Eligibility System(1.800.DIAL.CDH)*

• or by checking the mostcurrent Eligibility Report sent to your office on amonthly basis.

WHAT HAPPENS WHEN ELIGIBILITYCANNOT BE VERIFIED?Sometimes enrollment informa-tion is sent late from theemployer. Therefore wheneligibility cannot be verified, the office may:• charge the member its usual

fees when services arerendered, OR

• bill the member at a later date.

Upon receipt of a retroactivecapitation payment from CIGNADental for a member whosecoverage was later confirmed, theoffice should refund any usual feethe member has paid.

If a patient is listed as eligible atthe time of service, but is laterfound to be ineligible, theNetwork General Dentist mayseek payment from the patient.

Patient ChargeSchedulesA spectrum of benefit options aremade available to employersselecting the CIGNA Dental Careplan. The Patient Charge Scheduleoutlines the specific benefit levelselected by the group, lists allcovered procedures, and states themembers’ associated out-of-pocketexpenses (patient charges). TheNetwork General Dentist may notcharge the patient more than thelisted patient charge. CIGNADental provides a copy of theapplicable Patient Charge Scheduleto the member at the time ofenrollment. The “Patient ChargeSchedules At A Glance” bookletenclosed with this Quick ReferenceGuide lists all the standard CIGNADental Patient Charge Schedulesfor your reference.

MEMB

ERIN

FORM

ATIO

N

*Available 24 hours a day, 7 days a week.

9

Members FinancialResponsibility• Procedures listed on the

Patient Charge Schedule – Asa Network General Dentist,you perform all necessarycovered services and collect allapplicable patient chargesdirectly from the member.

• Procedures not listed on thePatient Charge Schedule –Procedures NOT LISTED onthe Patient Charge Scheduleare not covered and you cancharge your usual fee. Forclarification refer to the chartlisting the “Most CommonlyPerformed Procedures” in thePolicy Manual.

• Inclusive charges – Thepatient cannot be chargedadditional fees for services that are not defined asseparate procedures in theCurrent Dental Terminologymanual. Any such charge must be considered inclusiveto the major procedureperformed such as routinetemporary crowns and bridges. With regard to localanesthetic, the ADA maintainsthat local anesthetic is to beinclusive to the procedureperformed and no additionalcharge can be made.

• Procedures performed by a specialist – The patientcharges listed on the Patient Charge Schedule also apply to those sameprocedures performed by aNetwork Specialist. Refer to the Specialty ReferralGuidelines in this guide formore information.

• When non-covered services are offered to the patient,comparable covered servicesshould also be offered.

OFFICE VISIT PATIENT CHARGE SCHEDULESCIGNA Dental has developedseveral Patient Charge Scheduleswhich include a patient-paidoffice visit fee. These schedulesare identified with a “V” in thename of the schedule, e.g. FV-02.If a member is covered on anoffice visit schedule, the memberis responsible for the visit fee foreach office visit, PLUS theapplicable patient charge for the procedure.

UNIQUE PATIENT CHARGE SCHEDULESA unique Patient Charge Scheduleis a schedule created exclusivelyfor a specific group or employer.A unique schedule may expire orbe added during the year. Pleasecheck your eligibility report forthe most current information andrequest a copy of any uniquePatient Charge Schedules fromthe Provider Service Organizationat 1.800.DIAL.CDH (342.5234).

Member EducationWe have included in thisreference guide, “Understandingand Getting the Most from YourCIGNA Dental Plan” to copy anduse as needed. This document willprovide information and clarifyconcerns for members who selectyour office.

MEMBERINFORMATION

10

UNDERSTANDING AND GETTING THE MOST FROM YOUR CIGNA DENTAL PLAN

Below you’ll find answers to the most commonly asked questions about your dental plan.If you have further questions, please call Member Services at 1.800.367.1037.

HOW DO I KNOW WHAT’S COVERED?Covered services are listed on your Patient Charge Schedule. Your plan booklet also contains helpful informationabout exclusions and limitations of covered services.

IF THERE IS A COST, HOW IS IT HANDLED?Your Patient Charge Schedule lists procedures that require payment, which is due at the time the service isprovided. Make sure you understand all charges associated with your treatment plan. Check with your dentist tosee what payment options are available.

WHAT HAPPENS IF I MISS AN APPOINTMENT?24 hours notice is required if you need to cancel an appointment. If you fail to keep an appointment or arrive late,you may be charged a broken appointment fee.

WHAT DO I DO IN CASE OF AN EMERGENCY?If you are experiencing bleeding, acute pain or apparent infection contact your assigned network general dentist.Your assigned office is expected to see you within 24 hours or sooner based on medical necessity. If you are out oftown, please call Member Services at 1.800.367.1037 to receive authorization to visit another dentist. You will bereimbursed according to your plan’s emergency care benefit for relief of pain only. Routine restorative proceduresor definitive treatment (e.g. root canal) are not considered emergency care. You should return to your networkgeneral dentist should these procedures be required.

WHAT IF I NEED A SPECIALIST?Your network general dentist will evaluate your condition and will refer you, if necessary, to a specialist. Thecopayment listed on your Patient Charge Schedule applies at the specialist’s office as well as the general dentist’s office.

CAN I CHANGE DENTIST?Yes, you can make changes by calling our 24-hour automated dental office locator, contacting a Member ServiceRepresentative at 1.800.367.1037, or visiting our website at www.cigna.com. Any treatment in progress must becompleted before you transfer. Transfers are effective the first of the following month.

WHAT ARE MY RESPONSIBILITIES?Read and understand your Plan Booklet and Patient Charge Schedule (PCS). Contact Member Services at1.800.367.1037 for clarification or to request a copy of your PCS.

Home care, nutrition, and routine check ups are crucial in maintaining your dental health.

Talk with your dentist and his/her staff. They can answer questions, explain treatment and discuss optionsregarding your treatment plan. The more you understand, the better decisions you and your dentist can maketogether.

Be sure to keep your employer and CIGNA Dental up-to-date regarding any changes in address, phone number,number of covered dependents, or any other change in your coverage status. Maintaining accurate records helpsus serve you better.

▲▲

www.cigna.com Dental

SAVE AND COPY AS NEEDED:

▲▲

11

AdministrativeProcedures

PatientEncounter DataCIGNA Dental requiressubmission of patient encounterdata for covered procedures thatyou render to CIGNA Dental Caremembers. Submission of patientencounter data is extremelyimportant because it is used inthe following ways:

COMPENSATIONPatient encounter data submittedto CIGNA Dental is the basis forcompensation in the form ofsupplemental and office visitpayment, as applicable.

STATISTICAL REPORTSCIGNA Dental sends monthlystatistical reports to each network office. These reports arebased on patient encounter dataand contain the followinginformation:• number of chair hours for

procedures performed by each network dentist

• number of total chair hours for procedures performed atthe office

• procedures performed listed by major dental procedurecategories and by individualnetwork dentist

• income generated from fixedmonthly payments, patientcharges and supplementalpayments (if applicable) forprocedures performed by the office.

PATIENT RECALL INFORMATIONCIGNA Dental has developed anautomated recall system to helpyou maintain an appropriaterecall schedule for members.The recall date section on thePatient Encounter Form allowsCIGNA Dental to generatepatient recall cards, pre-addressed and ready for you tomail prior to the recall date.

UTILIZATION/REFERRAL PATTERNSPractice patterns and proceduresare routinely monitored throughour Utilization Review program.Specifically, we review thenumber of procedures reportedby an individual dentist andcompare that with the norm forthat particular area.

ADMINISTRATIVEPROCEDURES

12

Administrative Procedures (continued)

How to SubmitEncounter DataYou can submit encounterinformation by using one of the following methods:

ELECTRONIC ENCOUNTERPlease refer to the “Benefits forNetwork Dentists” section –“Electronic Filing of EncounterData” of this Quick ReferenceGuide. The pull-out included inthis Quick Reference Guide alsoprovides instructions on how tosubmit encounters electronically.

PATIENT ENCOUNTER FORMThe CIGNA Dental PatientEncounter Form is a pre-printedform which includes informationnecessary to report accuratepatient service information.These forms are supplied byCIGNA Dental. They should becompleted at each member’sdental visit and sent to CIGNADental on a weekly basis.

COMPUTER PRINTOUTSCIGNA Dental is pleased to allowyou to send patient encounterdata via a computer generatedprintout if it is compatible withCIGNA Dental’s processingsystem. To verify compatibility,please forward a list of theprocedure codes and descriptionsused by your office to the DataEntry Supervisor of CIGNADental prior to submitting yourfirst printout.

Computer generated printoutsshould include the followinginformation:• run date of report;

• your CIGNA Dental officenumber; e.g. D123456

• name of dental office;

• subscriber’s ID number;

• subscriber’s last name;

• patient’s last name and first name;

• patient’s relationship with subscribers; e.g. S (spouse), C (child)

• license number of treating dentist;

• treatment date;

• procedure code;

• procedure description;

• tooth number, arch or quadrant code;

• number of services; and

• recall date (this is only if you would like CIGNA Dental to generate your office recall cards).

Clear delineation between patientencounters is required, e.g., skipone line between each patient.

IN-HOUSE SPECIALIST SUBMISSIONPlease refer to the administra-tive policies section in the Policy Manual.

ENCOUNTER DATA 90-DAY VALIDATION PERIODIn order to maintain the integrityof encounter data statistics,network general dentists arerequired to submit encounterdata on a weekly basis. Encounterdata is not accepted beyond 90days of the service date.*

*Exception in Maryland – 180 days.

ADMI

NIST

RATIV

EPR

OCED

URES

13

ENCOUNTER DATA SUBMITTED AFTER90-DAY VALIDATION PERIODCIGNA will notify the NetworkGeneral Dentist of data rejecteddue to submission beyond the90-day validation period. Theseitems will appear on theencounter error report (page 15).Please contact the ProviderService Organization(1.800.DIAL.CDH) if you haveany questions regardingencounter errors. CIGNA Dentalwill investigate and decide whataction, if any, can be taken.

Where to SendEncounter DataYou may use the pre-addressedenvelopes supplied by CIGNADental or your officeenvelopes. We encourage youto mail patient encounter datato CIGNA Dental weekly.

For all states except California,mail to:

CIGNA DentalP.O. Box 189061Plantation, FL 33318-9061

For California, mail to:CIGNA DentalP.O. Box 2125Glendale, CA 91209-2125

For encounters received andprocessed after the third Friday ofthe month, all data andassociated payments will appearon the following month’s reportand check.

Encounter ErrorReportWhen patient encounterinformation is submittedand unable to be processed,

an Encounter Error Report isgenerated indicating theunprocessed information with a blank line. This report is included in your monthlypackage (see exhibit). To update CIGNA Dental with the appropriate information:

• Indicate the updatedinformation on theEncounter Error Report in blank line area only.

• Return the completedEncounter ErrorReport to the same address used for encounter submissions.

Supplemental Payments andOffice Visit Payments (ifapplicable) will be providedafter the corrected informationis processed. On the followingpage is a list of encounter errordescriptions and whether acorrection is needed.


14

CorrectionNeeded

Y

Y

Y

Y

Y

Y

N

N

Y

Y

Y

Y

N

Y

N

N

N

Description

The member ID number is not in the CIGNA Dental system.

The member ID number was not provided.

The patient name listed is not in the CIGNA Dental system as a covered dependent for the subscriber indicated. Please submit encounters under thename as reported on your CIGNA Dental eligibility report.

The member ID number is invalid for the member name.

The CIGNA Dental Care member listed was not assigned to your office at thetime of treatment. If this visit was for a 2nd opinion or emergency, pleasesubmit a bill to the Specialty Referral Department for payment.

The treatment date for the procedures listed was missing, incomplete, orinvalid.

Procedures were not indicated for member. Please resubmit this encounter.

The encounter data listed exceeded the 90-day limit for entry into theCIGNA Dental system.

A broken appointment and services have been marked on the encounterform for the same treatment date for this patient. Please cross off theprocedure code(s) that do not apply.

The procedure code submitted is not a valid dental procedure code.

The procedure listed requires a tooth number or quadrant.

The tooth number or quadrant indicated is not valid for the procedure listed.

The member was inactive at the time of treatment.

The procedure code listed is not a covered benefit according to the member’sCIGNA Dental Care charge schedule.

Prior procedure required.

This service not covered due to a previously rendered service.

This procedure is not valid from a network general dentist.

Code

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

Encounter Errors

ENCOUNTER ERRORSDescriptions to assist you in correcting encounter errors.

ADMI

NIST

RATIV

EPR

OCED

URES

15

ENCOUNTER ERROR REPORT SAMPLE:Details errors to provide an opportunity to indicate corrections and submit for processing.

RUN DATE 01/02/2003 CIGNA DENTAL HEALTH, TESTING MNMR0387 PAGE 12FOR: 12/2002 ENCOUNTER ERROR REPORT XX 999999

DENTAL OFFICE ID: D999999 OBSOLETE, FACILITY #: XX999

The following encounters were submitted with errors. Please correct the data where approrpirate on the blank line provided belowthe incorrect data and return this report to CDH. Supplemental payments and office visit payments will be processed whenthe corrected information is received. Please verify that the procedure codes listed are valid for the member's patientcharge schedule. Invalid codes will not be returned a second time.

ENCOUNTERMEMBER

MEMBER IDNUMBER

MEMBERNAME TREATMENTDATE

PROCEDURE TOOTH/QUAD

ERROR MESSAGE

----------------------------------------------------------------------------------------------------------------------------------25352759 999999999-02 SMITH, LISA 11/10/2002 D2150 AMALG-PERM 2 SURF *THE PROCEDURE LISTED REQUIRES A

TOOTH NUMBER OR QUADRANT

D0220 X-RAYS - SINGLE FM

----------------------------------------------------------------------------------------------------------------------------------25543285 999999999-01 SMITH, ALAN 11/25/2002 D1110 PROPHYLAXIS-ADULT FM *PROCEDURE D1110

(PROPHYLAXIS-ADULT) MAY NOT BEPERFORMED WITHIN 120 DAYS AFTERD1110 (PROPHYLAXIS-ADULT)

----------------------------------------------------------------------------------------------------------------------------------25543747 999999999-03 SMITH, CASSANDRA 12/04/2002 D3310 ANTERIOR RT CANAL *THE PROCEDURE LISTED REQUIRES A

TOOTH NUMBER OR QUADRANT

----------------------------------------------------------------------------------------------------------------------------------25576056 888888888-01 MC CORMICK, UNKNOWN 12/04/2002 *THE MEMBER ID NUMBER IS INVALID

FOR THE MEMBER NAMED6930 RECEMENT BRIDGE 19D6930 RECEMENT BRIDGE 20D6930 RECEMENT BRIDGE 21

----------------------------------------------------------------------------------------------------------------------------------25354835 777777777- JONES, VICTORIA 10/28/2002 *THE MEMBER ID NUMBER IS NOT IN

THE CDH SYSTEM

D7110 EXTRACTION - SINGLE 4

* QUESTIONS or CONFLICTS **Call your Network Management department to resolve issues if you question or disagree with an error message


16

Administrative Procedures (continued)

Monthly ReportsBelow are the names anddescriptions of the reports thatare sent to you in your monthlypayment package. Sample reportsare included in this QuickReference Guide for your review.

MEMBER/GROUP ELIGIBILITYAND PAYMENT:(SEE REPORT SAMPLE MNMR0005)• Lists specific information

about the Member/Groupeffective and renewal date.

• Indicates group compensationand plan benefit information,including pending changes.

• Details monthly payment adjustments

SUPPLEMENTAL PAYMENTS:(SEE REPORT SAMPLE MNMR0384)• Details additional

compensation (if applicable)provided by CIGNA Dental forspecific services based uponencounter data submitted byyour office (refer to theSupplemental Fee Scheduleattached to your NetworkGeneral Dentist Agreement forfurther information).

OFFICE VISIT PAYMENT LIST:(SEE REPORT SAMPLE MNMR0409)• Indicates the amount CIGNA

Dental has paid for eachmember visit based uponencounter data submitted byyour office (if applicable).

MONTHLY DENTAL OFFICESTATISTICAL REPORT:(SEE REPORT SAMPLE MNMR0450)• Contains month-to-date

and year-to-date analysis of all procedures performed by each network dentist inyour office, as well as a total of all treatment provided to members.

• Details usage for proceduresreferred from the dental office to specialists.

MONTHLY DENTAL OFFICE ANALYSIS:(SEE REPORT SAMPLE MNMR0451)• Lists month-to-date and year-

to-date income data and keystatistical information foryour office.

ADMI

NIST

RATIV

EPR

OCED

URES

17

MEMBER LIST BY DENTAL OFFICE (MMR0005) SAMPLE:The first section of the report lists all members assigned to your office for the current month andindicates the fixed monthly payment received, and any applicable backcharges, backpays or adjustments.RUN DATE 01-NOV-2002 CIGNA DENTAL HEALTH, INC. - CALIFORNIA MNMR0005 PAGE 1AS OF DATE: 01-NOV-2002 MEMBER LIST BY DENTAL OFFICE CA 117727

DENTAL OFFICE ID: D110000 ABC DENTAL GROUP

Member Name Mbr ID# Rel. Status PCS Group # Grp Name DOBEffctvDate

TermDate

MthlyPay

RetroPay

Retro/New Cap Date

ReasonCode

AH HONG, IVANHO 000-73-8359-02 SP ACTIVE G1-03 G10034569 CSEBA OF CALIFO 05-DEC-1972 01-JUL-2001 2.55 01-NOV-2002AH-HONG, SULIANA K 000-73-8359-01 SU ACTIVE G1-03 G10034569 CSEBA OF CALIFO 22-JAN-1972 01-JUL-2001 2.55 01-NOV-2002ALBARENGA, DAISY 000-74-2437-05 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 21-APR-1991 01-SEP-2001 1.61 01-NOV-2002ALBARENGA, IRIS E 000-74-2437-06 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 01-SEP-2002 11-SEP-2002 1.61 01-NOV-2002 NALBARENGA, IRIS E 000-74-2437-06 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 01-SEP-2002 01-SEP-2002 1.61 01-SEP-2002 NALBARENGA, IRIS E 000-74-2437-06 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 01-SEP-2002 01-OCT-2002 1.61 01-OCT-2002 NALBARENGA, JAIME 000-74-2437-04 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 17-AUG-1996 01-SEP-2001 1.61 01-NOV-2002ALBARENGA, JOSE 000-74-2437-02 SP ACTIVE K1-04 G10052498 THE CHEESECAKE 17-DEC-1966 01-SEP-2001 2.86 01-NOV-2002ALBARENGA, RENE 000-74-2437-03 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 17-DEC-1987 01-SEP-2001 1.61 01-NOV-2002ANGEL, EVANGELINE F 000-36-5970-01 SU ACTIVE T1-03 G10003481 LAUSD RETIREES 16-OCT-1929 01-JUL-2001 3.98 01-NOV-2002ANGEL, RAY G 000-36-5970-03 SP ACTIVE T1-03 G10003481 LAUSD RETIREES 18-OCT-1927 01-JUL-2001 3.98 01-NOV-2002ARANA, JILMER 000-44-6745-01 SU ACTIVE K1-04 G10052498 THE CHEESECAKE 21-NOV-1977 01-OCT-2002 2.86 01-NOV-2002 NARANA, JILMER 000-44-6745-01 SU ACTIVE K1-04 G10052498 THE CHEESECAKE 21-NOV-1977 01-OCT-2002 2.86 01-OCT-2002 NAUGUSTT, AMBROSE Y 000-64-2527-01 SU ACTIVE T1-03 G10003484 LOS ANGELES UNI 01-JUL-1951 01-SEP-2001 3.98 01-NOV-2002AUGUSTT, CADEISHA E 000-64-2527-02 NS ACTIVE T1-03 G10003484 LOS ANGELES UNI 08-APR-1995 01-SEP-2001 2.25 01-NOV-2002AUGUSTT, CALEB E 000-64-2527-04 NS ACTIVE T1-03 G10003484 LOS ANGELES UNI 22-NOV-1992 01-SEP-2001 2.25 01-NOV-2002AUGUSTT, EDITH K 000-64-2527-03 SP ACTIVE T1-03 G10003484 LOS ANGELES UNI 05-JUL-1966 01-SEP-2001 3.98 01-NOV-2002AUGUSTT, ELORM C 000-64-2527-05 NS ACTIVE T1-03 G10003484 LOS ANGELES UNI 13-AUG-1996 01-SEP-2001 2.25 01-NOV-2002BARILLAS, JULIO R 000-29-3623-01 SU ACTIVE F1-04 G10019809 JTB AMERICAS, L 01-JAN-1959 01-APR-1998 4.47 01-NOV-2002BARRERA, MARILONA 000-95-8225-01 SU ACTIVE K1-04 G10052498 THE CHEESECAKE 16-AUG-1950 01-OCT-2002 2.86 01-NOV-2002 NBARRERA, MARILONA 000-95-8225-01 SU ACTIVE K1-04 G10052498 THE CHEESECAKE 16-AUG-1950 01-OCT-2002 2.86 01-OCT-2002 NBARRON, ANTHONY 000-97-7417-04 NS ACTIVE F1-04 G10081568 LIBERTY MEDIA C 20-OCT-1997 01-SEP-2001 2.51 01-NOV-2002BARRON, ELIZABETH 000-97-7417-05 NS ACTIVE F1-04 G10081568 LIBERTY MEDIA C 02-FEB-2001 01-SEP-2001 2.51 01-NOV-2002BARRON, JAIME 000-97-7417-02 SP ACTIVE F1-04 G10081568 LIBERTY MEDIA C 24-NOV-1972 01-SEP-2001 4.47 01-NOV-2002BARRON, JAIME 000-97-7417-03 NS ACTIVE F1-04 G10081568 LIBERTY MEDIA C 24-FEB-1992 01-SEP-2001 2.51 01-NOV-2002BARRON PAZ, MARIA 000-97-7417-01 SU ACTIVE F1-04 G10081568 LIBERTY MEDIA C 16-FEB-1973 01-SEP-2001 4.47 01-NOV-2002BARTLETT, COLLEEN J 000-66-1623-01 SU ACTIVE T1-03 G10003479 LOS ANGELES UNI 17-DEC-1946 01-APR-2000 3.98 01-NOV-2002BARTLETT, LISA B 000-66-1623-03 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 15-MAR-1985 01-APR-2000 2.25 01-NOV-2002BARTLETT, SARA B 000-66-1623-02 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 20-JAN-1983 01-APR-2000 2.25 01-NOV-2002BODOYA, DELIA 000-94-5715-01 SU ACTIVE W1-04 G10081971 CONTINENTAL CUR 07-JUL-1969 01-MAY-2002 3.32 01-NOV-2002CARRERA, ARTEMIO 000-08-5864-01 SU ACTIVE K1-04 G10086095 SWH CORPORATION 20-OCT-1973 01-JUN-2002 2.86 01-NOV-2002CARRERA, ARTEMIO 000-08-5864-03 NS ACTIVE K1-04 G10086095 SWH CORPORATION 03-MAR-1993 01-JUN-2002 31-MAR-2012 1.61 01-NOV-2002CARRERA, EDGAR 000-08-5864-04 NS ACTIVE K1-04 G10086095 SWH CORPORATION 12-MAY-1996 01-JUN-2002 31-MAY-2015 1.61 01-NOV-2002CARRERA, FRANCISCA 000-08-5864-02 SP ACTIVE K1-04 G10086095 SWH CORPORATION 12-OCT-1973 01-JUN-2002 2.86 01-NOV-2002CASTRO, ERICKA M 000-20-0798-01 SU ACTIVE K1-04 G10080845 HAWKER PACIFIC 21-AUG-1977 01-JUN-2002 2.86 01-NOV-2002CERVANTES, MANUEL 000-41-4444-01 SU ACTIVE T1-03 G10003484 LOS ANGELES UNI 06-APR-1965 01-DEC-1999 3.98 01-NOV-2002DAVIS, RICHARD 000-97-0993-01 SU ACTIVE F1-04 G10081568 LIBERTY MEDIA C 24-JUN-1975 01-APR-2002 4.47 01-NOV-2002DE OLIVEIRA, SANDRA 000-77-7179-01 SU ACTIVE F1-04 G10078415 SIMON WIESENTHA 03-JUL-1977 01-JUL-2002 4.47 01-NOV-2002DEL CARPIO, ANA 000-48-9165-04 SP ACTIVE T1-04 G10062964 RICON CORPORATI 09-JAN-1965 01-SEP-2001 3.35 01-NOV-2002DENEGRI, ALBERTO A 000-48-9165-01 SU ACTIVE T1-04 G10062964 RICON CORPORATI 08-APR-1965 01-APR-2001 3.35 01-NOV-2002DENEGRI, VANESSA 000-48-9165-03 NS ACTIVE T1-04 G10062964 RICON CORPORATI 03-MAR-2000 01-SEP-2001 1.89 01-NOV-2002DRAGAN, CODRINA 000-65-4339-01 SU ACTIVE L1-04 G10049922 NRT INCORPORATE 20-DEC-1968 01-MAY-2002 3.90 01-NOV-2002EHTESHAMI, SORAYA 000-72-7946-01 SU ACTIVE T1-03 G10003479 LOS ANGELES UNI 15-DEC-1951 01-FEB-2000 3.98 01-NOV-2002FELIX, GABRIEL 000-18-7872-01 SU ACTIVE T1-03 G10003484 LOS ANGELES UNI 24-MAR-1981 01-AUG-2000 3.98 01-NOV-2002GARCIA, JULISSA Y 000-76-7410-04 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 20-JUL-2001 01-SEP-2001 2.25 01-NOV-2002

Sub/Dep: SU=SUBSCRIBER SP=SPOUSE NS=NON-SPOUSE DEPENDENTFLAG: N=NEW ADDITION TI=TRANSFER IN TO=TRANSFER OUT R=REINSTATEMENT C=PCS CODE CHANGE E=EFF DATE CHANGE I=INACTIVATED B=BEN GROUP CHANGE


RUN DATE 01-NOV-2002 CIGNA DENTAL HEALTH, INC. - CALIFORNIA MNMR0005 PAGE 2AS OF DATE: 01-NOV-2002 MEMBER LIST BY DENTAL OFFICE CA 117727


Member Name Mbr ID# Rel. Status PCS Group # Grp Name DOBEffctvDate

TermDate

MthlyPay

RetroPay

Retro/New Cap Date

ReasonCode

GOMEZ, ARTURO 000-24-1708-01 SU ACTIVE KV-04 G10081602 TELEVISA INTERN 06-AUG-1973 01-MAR-2002 2.86 01-NOV-2002GOMEZ, ARTURO 000-24-1708-04 NS ACTIVE KV-04 G10081602 TELEVISA INTERN 07-FEB-1996 01-MAR-2002 1.61 01-NOV-2002GOMEZ, MAXIMINO 000-97-0369-01 SU ACTIVE F1-04 G10019858 400 PBG 25-DEC-1976 06-APR-1998 4.47 01-NOV-2002GOMEZ, YESENIA 000-24-1708-03 NS ACTIVE KV-04 G10081602 TELEVISA INTERN 07-FEB-1996 01-MAR-2002 1.61 01-NOV-2002GONZALEZ, CHRISTINA 000-24-1708-02 NS ACTIVE KV-04 G10081602 TELEVISA INTERN 30-NOV-1994 01-MAR-2002 1.61 01-NOV-2002GONZALEZ PINEL, TERE 000-83-7627-01 SU ACTIVE T1-03 G10003479 LOS ANGELES UNI 25-AUG-1969 01-JAN-1999 3.98 01-NOV-2002GUZMAN, MARLENY M 000-18-0490-01 SU INACTIVE G10058348 CREST NATIONAL 30-DEC-1966 01-NOV-2002 31-OCT-2002 0.00 01-NOV-2002 ILAMBERT, JEROME 000-49-3547-02 SP ACTIVE F1-04 G10074160 FISERV 01-DEC-1962 01-OCT-2000 4.47 01-NOV-2002LAMBERT, PIRIN 000-49-3547-04 NS ACTIVE F1-04 G10074160 FISERV 03-OCT-1991 01-OCT-2000 03-OCT-2010 2.51 01-NOV-2002LAMBERT, PORNTIPPA 000-49-3547-03 NS ACTIVE F1-04 G10074160 FISERV 19-NOV-1987 01-OCT-2000 19-NOV-2006 2.51 01-NOV-2002LAMBERT, TIDA 000-49-3547-05 NS ACTIVE F1-04 G10074160 FISERV 01-JUL-1993 01-OCT-2000 01-JUL-2012 2.51 01-NOV-2002LAMBERT, VIPAPORN P 000-49-3547-01 SU ACTIVE F1-04 G10074160 FISERV 23-NOV-1957 01-OCT-2000 4.47 01-NOV-2002LEON, JORGE 000-68-9804-01 SU ACTIVE L1-04 G10001371 JERRY'S FAMOUS 01-OCT-1964 01-AUG-2002 3.47 01-NOV-2002LOPEZ, GUADALUPE 000-99-5469-01 SU ACTIVE W1-04 G10001066 PIASC BENEFIT T 23-JUL-1965 01-JUN-1998 2.52 01-NOV-2002LUNA, MARIA 000-72-5172-01 SU ACTIVE K1-04 G10052498 THE CHEESECAKE 18-MAY-1949 01-SEP-1999 2.86 01-NOV-2002MACEDO, FELIPE 000-07-6217-01 SU ACTIVE K1-04 G10048836 VIBA INSURANCE 21-APR-1964 01-APR-1998 2.86 01-NOV-2002MACEDO, VILDA 000-07-6217-02 SP ACTIVE K1-04 G10048836 VIBA INSURANCE 27-NOV-1956 01-NOV-2000 2.86 01-NOV-2002MAROUEZ, JAIME 000-48-9165-05 NS ACTIVE T1-04 G10062964 RICON CORPORATI 15-MAY-1984 01-JUN-2001 1.89 01-NOV-2002MARTINEZ, PEDRO 000-48-0885-01 SU ACTIVE FV-04 G10061228 ADIR INTERNATIO 24-DEC-1965 01-JUN-2000 4.47 01-NOV-2002MARTINEZ, RAMON 000-67-0882-01 SU ACTIVE B1-04 G10038600 ACTIVE & COBRA 27-MAY-1973 01-APR-1998 4.98 01-NOV-2002MENDEZ, DALILE V 000-53-7178-01 SU ACTIVE T1-03 G10003479 LOS ANGELES UNI 23-OCT-1977 01-JAN-2001 3.98 01-NOV-2002MOGHBELI, FARAMARZ 000-72-7946-02 SP ACTIVE T1-03 G10003479 LOS ANGELES UNI 20-FEB-1945 01-FEB-2000 3.98 01-NOV-2002MOGHBELI, KIAN 000-72-7946-03 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 15-APR-1982 01-FEB-2000 2.25 01-NOV-2002MOGHBELI, SHABNAM 000-72-7946-05 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 01-JAN-1986 01-FEB-2000 2.25 01-NOV-2002MOLINA, YOLANDA 000-24-3910-01 SU ACTIVE F1-04 G10033623 AAOHC/F1/LOS AN 05-OCT-1963 01-APR-2002 4.24 01-NOV-2002MURILLO, MARIA 000-18-7781-02 SP ACTIVE W1-04 G10036608 FINISHMASTER 14-SEP-1953 01-JAN-1999 2.66 01-NOV-2002MURILLO, MARINA 000-18-7781-03 NS ACTIVE W1-04 G10036608 FINISHMASTER 26-MAR-1988 01-JAN-1999 1.49 01-NOV-2002MURILLO, MARIO A 000-18-7781-01 SU ACTIVE W1-04 G10036608 FINISHMASTER 22-MAR-1957 01-JAN-1999 2.66 01-NOV-2002NAVARRO, AUGUSTUS F 000-90-1099-01 SU ACTIVE L1-04 G10035899 SPECIAL DEVICES 17-AUG-1979 01-OCT-1998 3.47 01-NOV-2002NICKOLS, NICHOLAS GE 000-81-0516-01 SU INACTIVE GV-04 G10061504 UCLA/SEMESTRAL 12-APR-1978 01-SEP-2002 31-JUL-2002 -1.98 01-SEP-2002 INICKOLS, NICHOLAS GE 000-81-0516-01 SU INACTIVE GV-04 G10061504 UCLA/SEMESTRAL 12-APR-1978 01-OCT-2002 31-JUL-2002 -1.98 01-OCT-2002 INICKOLS, NICHOLAS GE 000-81-0516-01 SU INACTIVE GV-04 G10061504 UCLA/SEMESTRAL 12-APR-1978 01-NOV-2002 31-JUL-2002 0.00 01-NOV-2002 ENUNEZ, ALICIA 000-71-7733-01 SU ACTIVE W1-04 G10034761 VIBA VALLEY LOS 06-AUG-1976 01-JUL-2002 2.66 01-NOV-2002NUNEZ, XAVIER 000-71-7733-02 NS ACTIVE W1-04 G10034761 VIBA VALLEY LOS 16-APR-1996 01-JUL-2002 1.49 01-NOV-2002ORDONEZ, GUANERFE 000-48-6679-01 SU ACTIVE F1-04 G10046155 CHEVYS, INC. 19-MAR-1970 01-FEB-2001 4.47 01-NOV-2002PEREZ, DANNY 000-79-1370-01 SU ACTIVE LV-04 G10035659 FULL TIME LV-0 20-APR-1969 01-MAY-2002 4.34 01-NOV-2002PEREZ, VANESSA S 000-79-1370-04 NS ACTIVE LV-04 G10035659 FULL TIME LV-0 13-JAN-1994 01-MAY-2002 2.44 01-NOV-2002PICKENS, DANIEL 000-56-4234-03 NS ACTIVE F4-04 G10032564 NFL PROPERTIES 17-MAY-1991 01-NOV-2001 2.71 01-NOV-2002PINELA, DANIELLE M 000-83-7627-03 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 01-NOV-1993 01-JAN-1999 2.25 01-NOV-2002PINELA, JEANETTE T 000-83-7627-04 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 02-OCT-1994 01-JAN-1999 2.25 01-NOV-2002PINELA, LUIS A 000-83-7627-02 SP ACTIVE T1-03 G10003479 LOS ANGELES UNI 15-JUN-1966 01-JAN-1999 3.98 01-NOV-2002REYES, GERARDO 000-18-2559-01 SU ACTIVE F1-04 G10040505 SUNKIST GROWERS 19-OCT-1965 01-FEB-2002 4.47 01-NOV-2002RIAZ, MOHAMMAD 000-78-8279-01 SU ACTIVE T1-04 G10004392 PRIME WHEEL OF 01-APR-1965 01-APR-2002 3.35 01-NOV-2002RIAZ, RUBAB RIAZ 000-78-8279-02 SP ACTIVE T1-04 G10004392 PRIME WHEEL OF 23-OCT-1974 01-APR-2002 3.35 01-NOV-2002ROBB, ISABELLA J 000-89-8212-02 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 16-SEP-2002 16-SEP-2002 3.35 01-NOV-2002

2.25 01-NOV-2002 N


18AD

MINI

STRA

TIVE

PROC

EDUR

ES

MEMBER LIST BY DENTAL OFFICE (MMR0005) SAMPLE: (continued)

MEMBER LIST BY DENTAL OFFICE (MMR0005) SAMPLE: (continued)RUN DATE 01-NOV-2002 CIGNA DENTAL HEALTH, INC. - CALIFORNIA MNMR0005 PAGE 3AS OF DATE: 01-NOV-2002 MEMBER LIST BY DENTAL OFFICE CA 117727


ROBB, ISABELLA J 000-89-8212-02 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 16-SEP-2002 01-SEP-2002 2.25 01-SEP-2002 NROBB, ISABELLA J 000-89-8212-02 NS ACTIVE T1-03 G10003479 LOS ANGELES UNI 16-SEP-2002 01-OCT-2002 2.25 01-OCT-2002 NRODRIGUEZ, GUDI 000-11-4109-01 SU ACTIVE L1-04 G10037234 SWISSPORT 17-FEB-1970 01-AUG-2002 4.34 01-NOV-2002SIMS, JESSE T 000-32-5322-02 SP ACTIVE T1-03 G10003481 LAUSD RETIREES 11-AUG-1941 01-JUL-2002 3.98 01-NOV-2002SIMS, LILLIAN B 000-32-5322-01 SU ACTIVE T1-03 G10003481 LAUSD RETIREES 07-MAY-1940 01-APR-1998 3.98 01-NOV-2002SMITH, CHARLES 000-45-4038-01 SU ACTIVE F1-04 G10083260 DEVRY INC. 23-DEC-1974 01-AUG-2002 4.47 01-NOV-2002SMITH, MYIA 000-45-4038-02 SP ACTIVE F1-04 G10083260 DEVRY INC. 23-NOV-1979 11-JUL-2002 4.47 01-NOV-2002SUAREZ, ANABEL 000-74-2437-01 SU ACTIVE K1-04 G10052498 THE CHEESECAKE 21-NOV-1960 01-SEP-2001 2.86 01-NOV-2002TRUJILLO, FELIPE 000-20-2983-01 SU ACTIVE T1-04 G10062964 RICON CORPORATI 26-MAY-1966 01-MAR-2002 3.35 01-NOV-2002TUCK, AHMAD 000-56-4234-04 SP ACTIVE F4-04 G10032564 NFL PROPERTIES 31-DEC-1960 01-NOV-2001 4.82 01-NOV-2002TUCK, AUDREY YOU 000-56-4234-01 SU ACTIVE F4-04 G10032564 NFL PROPERTIES 13-JUN-1959 01-NOV-2001 4.82 01-NOV-2002URRUTIA, JAIMIE 000-07-5674-03 NS ACTIVE K1-04 G10062325 CALIFORNIA 15-JUL-1989 01-JUN-2000 1.61 01-NOV-2002URRUTIA,RANDY 000-07-5674-04 NS ACTIVE K1-04 G10062325 CALIFORNIA 11-SEP-1997 01-JUN-2000 1.61 01-NOV-2002URRUTIA, REYNALDO 000-07-5674-01 SU ACTIVE K1-04 G10062325 CALIFORNIA 29-SEP-1956 01-JUN-2000 2.86 01-NOV-2002URRUTIA, ROLAND 000-07-5674-02 NS ACTIVE K1-04 G10062325 CALIFORNIA 25-JUN-1985 01-JUN-2000 1.61 01-NOV-2002VALIENTE, DINA R 000-48-6950-02 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 20-MAY-1988 01-FEB-2000 1.61 01-NOV-2002VALIENTE, JOSE 000-48-6950-01 SU ACTIVE K1-04 G10052498 THE CHEESECAKE 01-MAY-1958 01-FEB-2000 2.86 01-NOV-2002VALIENTE, ROBERTO C 000-48-6950-05 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 12-DEC-1984 01-FEB-2000 1.61 01-NOV-2002VALIENTE, ROSA 000-48-6950-04 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 03-MAR-1983 01-FEB-2000 1.61 01-NOV-2002VALIENTE, WENDY 000-48-6950-03 NS ACTIVE K1-04 G10052498 THE CHEESECAKE 07-APR-1996 01-FEB-2000 1.61 01-NOV-2002WADE, STACY S 000-89-8212-01 SU ACTIVE T1-03 G10003479 LOS ANGELES UNI 27-MAY-1970 01-SEP-2001 3.98 01-NOV-2002WILKINS, AIMEE NYDIA 000-04-3409-03 SP ACTIVE T1-03 G10003479 LOS ANGELES UNI 18-AUG-1977 01-APR-2000 3.98 01-NOV-2002WILKINS, MARK T 000-04-3409-01 SU ACTIVE T1-03 G10003479 LOS ANGELES UNI 14-DEC-1956 01-DEC-1999 3.98 01-NOV-2002

TOTAL FOR 01-NOV-2002 314.48 9.48


19ADMINISTRATIVE

PROCEDURES

MEMBER LIST BY DENTAL OFFICE (MMR0005) SAMPLE:The last section of the report provides a summary of all compensationfor current month and year-to-date.

SUPPLEMENTAL PAYMENTS (MMR0384) SAMPLE:Indicates the amount of additional compensation CIGNA Dental has paid for specific servicesbased upon encounter data submitted by your office.

RUN DATE 01-NOV-2002 CIGNA DENTAL HEALTH, INC. - CALIFORNIA MNMR0005 PAGE 4AS OF DATE: 01-NOV-2002 MEMBER LIST BY DENTAL OFFICE CA 117727


------------------------- M T D -------------------------- ------------------------ Y T D ---------------------------General Supplmtl Ofc Visit Other Adj Total General Suplmtl Ofc Visit Other Adj Total

SUMMARY FOR 01-NOV-2002

Gross Payment 314.48 175.00 17.50 506.98 3,421.37 817.00 192.50 4,430.87Backcharges -3.96 -3.96 -226.87 -226.87Backpays 13.44 13.44 274.16 274.16Net Amount 323.96 175.00 17.50 516.46 3,468.66 817.00 192.50 4,478.16Total Check Amount 323.96 175.00 17.50 516.46 3,468.66 817.00 192.50 4,478.16Total Compensation 323.96 175.00 17.50 516.46 3,468.66 817.00 192.50 4,478.16

Number of Subscribers 47Number of Spouses 17Number of Non-Spouse Deps 39Total Number of Members 103

Number of New Members 4Number of Inactivated Members 3Number of Eff Date Changes 1

End of Report

RUN DATE 08-JAN-2003 CIGNA DENTAL HEALTH, - PENNSYLVANIA MNMR0384 PAGE 1FOR: 11/2002 SUPPLEMENTAL PAYMENTS CLOSING REPORT PA 100000

DENTAL OFFICE ID: D000001 OBSOLETE FACILITY #: PA000

MEMBERNAME

MEMBER IDNUMBER

TREATMENTDATE

PROCDRCODE

TOOTH/QUAD

TOTALREIMBURSEMENT CO-PAYMENT

SUPPLEMENTALPAYMENT

-------------------------------------------------------------------------------------------------------------------------SAMSONS, JOHN 000432472-01 10/15/2002 D1110 FM $1.50 $0.00 $1.50

MURPHY, JOHN 000461173-03 09/25/2002 D1120 FM $1.50 $0.00 $1.50

KESSLER, MARK 000454794-01 09/22/2002 D1110 FM $1.50 $0.00 $1.50

KESSLER, BUNNIE 000444597-02 10/14/2002 D3330 3 $300.00 $85.00 $215.00

GRAMLICH, JACK 000289162-01 10/15/2002 D5214 FM $300.00 $280.00 $20.00

SMITH, FRED 000270156-01 09/24/2002 D3330 14 $300.00 $250.00 $50.00

KRAMER, JIMMY 000685555-03 10/09/2002 D1120 FM $1.50 $0.00 $1.50-------------------------------------------------------------------------------------------------------------------------TOTAL CLOSED SUPPLEMENTAL PAYMENT $291.00-------------------------------------------------------------------------------------------------------------------------TOTAL SUPPLEMENTAL PAYMENT $291.00-------------------------------------------------------------------------------------------------------------------------YTD SUPPLEMENTAL PAYMENTS $1,184.50

--------------------------------|*** DENIED TRANSACTIONS ***|--------------------------------

MEMBERNAME

MEMBER IDNUMBER

TREATMENTDATE

PROCDRCODE

TOOTH/QUAD AMOUNT REASON DENIED

-------------------------------------------------------------------------------------------------------------------------MARTIN, STEVE 000565595-02 05/18/2002 D1110 FM $1.50 CONTRACT INACTIVE AT TIME OF TREATMENTPETREE, JOY 000439394-01 05/11/2002 D5110 FM $185.00 CONTRACT INACTIVE AT TIME OF TREATMENTJUSTIN, SHEILA 000860782-01 09/24/2002 D1110 FM $1.50 CONTRACT INACTIVE AT TIME OF TREATMENT

************************************************************************************** FOR QUESTIONS ABOUT SUPPLEMENTAL PAYMENTS, PLEASE CALL 1-800-DIAL-CDH. *******************************************************************************************

20AD

MINI

STRA

TIVE

PROC

EDUR

ES

OFFICE VISIT PAYMENT LIST (MNMR0409) SAMPLE:Indicates the amount CIGNA Dental has paid for each member utilizing your facilitybased upon encounter data submitted by your office.

RUN DATE 23-NOV-2002 CIGNA DENTAL HEALTH, - VIRGINIA MNMR0409 PAGE 1FOR: 05/2002 OFFICE VISIT PAYMENT LIST VA 000001

DENTAL OFFICE ID: D000001 OBSOLETE FACILITY #: VA999

------------------------------------------------------------------------------------------------------------------------------------**** OFFICE VISIT PAYMENT LIST ****------------------------------------------------------------------------------------------------------------------------------------

MEMBER NUM PATIENT TRTMNT GROUP AMT | MEMBER NUM PATIENT TRTMNT GROUP AMT|

000137950-02 HARRINGTON, ADRIENNE 04-24-2002 10029664-AE 3.50 | 000137950-01 HARRINGTON, RUBY 04-24-2002 10029664-AE 3.50000165412-01 BLANDING-JAY, SHEILA 05-06-2002 10037379-AE 3.50 | 000645252-01 BOLLERS, GARY 05-20-2002 10040486-AC 3.50000380621-02 BOWLES, ROBERTS 04-28-2002 10040486-AC 3.50 | 000588883-01 EDMOND, MONROE 05-15-2002 10040534-HU 3.50000112065-01 GOERTZ, RANDOLPH 04-27-2002 10032539-AE 3.50 | 000860059-01 GRANT, KANDY 05-20-2002 10039661-AE 3.50000680071-01 HAINESWORTH, ANTHONY 04-22-2002 10029824-AE 3.50 | 000804884-05 HOOT, JESSICA 05-06-2002 10029664-AE 3.50000602296-01 KUHNS, BETTY 04-28-2002 10036158-AE 3.50 | 000345310-01 MAYS, MERRILL 04-28-2002 10040486-AC 3.50000321176-02 MONTGOMERY, DENNIS 04-23-2002 10077734-AE 3.50 | 000379716-02 MONTGOMERY, MARCUS 05-07-2002 10017734-AE 3.50000502733-02 NILLPAN, DELORES 05-18-2002 10019858-AE 3.50 | 000741608-01 COHEN, BEVERLY 04-27-2002 10029664-AE 3.50000429494-01 PETREE, EVA 04-30-2002 10040486-AC 3.50 | 000289131-02 PHILLIPS, MARCY 04-29-2002 10006807-AE 3.50000429494-02 PHILLIPS, NANCY 05-06-2002 10006807-AE 3.50 | 000900437-03 POWERZ, ANDY 04-22-2002 10029664-AE 3.50000507495-03 JACKSON, DEKIMIA 04-27-2002 10032024-AE 3.50 | 000527230-01 ROSE, ROBERT 04-22-2002 10040486-AC 3.50000525709-01 ROSE, JONNIE 05-13-2002 10040486-AC 3.50 | 000523426-01 RUMPF, MELISSA 05-11-2002 10040486-AC 3.50

TOTAL PAID ECOUNTER FORMS: 24 84.00

------------------------------------------------------------------------------------------------------------------------------------**** OFFICE VISIT DENIAL LIST ****------------------------------------------------------------------------------------------------------------------------------------

MEMBER NUM PATIENT TRTMNT GROUP RSN | MEMBER NUM PATIENT TRTMNT GROUP RSN|

000494695-02 MARKIE, VERLA 05-18-2002 10006826-AE P | 000321404-01 PETREE, EVA 05-11-2002 10040486-AC P000326759-01 ROSE, JONNIE 05-11-2002 10040486-AC A | 000174952-01 WALTON, LAURIE 09-24-2002 10006826-AE X

TOTAL DENIED ENCOUNTER FORMS: 4

REASON CODE EXPLANATION: A = ALL PROCEDURES IN ERROR B = BROKEN APPOINTMENT C = PATIENT COPAYMENT D = DUPLICATE E = EXCEPTION NON-NEW OR RENEWING G = GROUP NOT ELIGIBLE FOR PAYMENT O = OFFICE EXCEPTION P = PATIENT INELIGIBLE R = RESUBMISSION REQUESTED S = SUPPLEMENAL PAYMENT CAPITATION T = STATE EXCEPTION W = WAITING FOR ERROR CORRECTION X = EXCEEDED 90 DAY LIMITATION

|----------------------------------------------------------------| | FAILURE TO REPORT DISCREPANCIES, IF ANY, WITH MONTHLY CDH DATA | | WITHIN THIRTY (30) DAYS OF RECEIPT BY PROVIDER SHALL SIGNIFY | | TO CDH FULL AGREEMENT AND ACCEPTANCE THEREOF BY PROVIDER. | |----------------------------------------------------------------|

End of Report

21ADMINISTRATIVE

PROCEDURES

MONTHLY DENTAL OFFICE STATISTICAL REPORT (MMR0450) SAMPLE:Contains a total of all treatment provided to members in your officeby procedure category.

RUN DATE 23-NOV-2002 CIGNA DENTAL HEALTH, - VIRGINIA MNMR0450 PAGE 4AS OF : 05/2002 MONTHLY DENTAL OFFICE STATISTICAL REPORT VA 000001DENTAL OFFICE ID: D000001

OBSOLETE FACILITY #: VA999 TOTAL GENERAL PROVIDER CARE

--------- CURRENT MONTH --------- ---------- YEAR-TO-DATE ---------- TOTAL ADA DESCRIPTION SERVICES CHAIR HRS %TOT HRS SERVICES CHAIR HRS %TOT HRS PAT-CHGE

A-DIAGNOSTIC/PREVENTIVED0110 ORAL EXAM-INITIAL 2 0.50 3.08 38 9.50 4.20D0120 ORAL EXAM-PERIODIC 5 1.25 7.69 59 14.75 6.52D0140 ORAL EVAL/PROBLEM 4 1.00 6.15 26 6.50 2.87D0150 COMP ORAL EVAL 0 0.00 0.00 3 0.75 0.33D0210 X-RAYS/COMPL SERIE 0 0.00 0.00 30 15.00 6.63D0220 X-RAYS - SINGLE 4 0.00 0.00 32 0.00 0.00D0230 X RAYS - EA ADD'TL 0 0.00 0.00 4 0.00 0.00D0272 X-RAYS/BITEWING 2 2 0.50 3.08 43 10.75 4.75D0330 X-RAYS/PANORAMIC 1 0.25 1.54 20 5.00 2.21D1110 PROPHYLAXIS-ADULT 5 3.75 23.08 68 51.00 22.54D1120 PROPHYLAXIS-CHILD 2 0.50 3.08 26 6.50 2.87D1203 FLUO/NO PROPHY-CHI 0 0.00 0.00 7 17.75 0.77 34D1330 ORAL HYG INSTRUCTI 0 0.00 0.00 3 0.00 0.00D1351 SEALANT-PER TOOTH 0 0.00 0.00 4 1.00 0.44 20D1515 SPACE MAIN-FIX BI 0 0.00 0.00 1 1.00 0.44 65

TOTAL-DIAGNOSTIC/PREVENTIVE 25 7.75 47.69 364 123.50 54.59 119

B-RESTORATIVED2120 AMALG-PRIM 2 SURF 0 0.00 0.00 6 1.50 0.66D2140 AMALG-PERM 1 SURF 4 1.00 6.15 15 3.75 1.66 12D2150 AMALG-PERM 2 SURF 6 3.00 18.46 167 8.50 3.76 32D2160 AMALG-PERM 3 SURF 0 0.00 0.00 4 3.00 1.33D2161 AMALG-PERM 4+ SURF 0 0.00 0.00 1 0.75 0.33 15D2339 RESIN-ANT 1 SURFAC 0 0.00 0.00 4 2.00 0.88D2331 RESIN-ANT 2 SURFAC 0 0.00 0.00 4 2.00 0.88D2332 RESIN-ANT 3 SURFAC 0 0.00 0.00 3 2.25 0.99 15D2335 RESIN 4+ SURF/ANT 0 0.00 0.00 4 3.00 1.33 260D2540 ONLAY/METALLIC 0 0.00 0.00 1 1.50 0.66 215D2940 SEDATIVE FILLING 0 0.00 0.00 8 4.00 1.77 5D2951 PIN RET/TOOTH+REST 0 0.00 0.00 1 0.25 0.11

TOTAL-RESTORATIVE 10 4.00 24.62 68 32.50 14.36 554

B-CROWN AND BRIDGED2740 CR RPOC/CER SUBSTR 0 0.00 0.00 1 2.00 0.88 275D752 CR PROC/NOBLE SUBSTR 0 0.00 0.00 9 18.00 7.96 1,450D2830 CR STAINLESS STEEL 0 0.00 0.00 1 0.75 0.33D2892 PREFAC POST & CORE 0 0.00 0.00 1 0.75 0.33 35D2920 RECEMENT CROWNS 0 0.00 0.00 2 0.50 0.22 10D2950 CORE BLDUP W/PINS 0 0.00 0.00 6 4.50 1.99 390D2954 PREFACB POST&CORE+C 0 0.00 0.00 1 0.75 0.33 75D6242 PONT/PORC-NOBLE ME 2 1.00 6.15 3 1.50 0.66 655D6752 ABUT/PORC-NOBL MET 2 3.00 18.46 2 3.00 1.33 400

22AD

MINI

STRA

TIVE

PROC

EDUR

ES

MONTHLY DENTAL OFFICE STATISTICAL REPORT (MMR0450) SAMPLE: (continued)Contains a total of all treatment provided to members in your officeby procedure category.


OBSOLETE FACILITY #: VA999 TOTAL GENERAL PROVIDER CARE


TOTAL-CROWN AND BRIDGE 4 4.00 24.62 26 31.75 14.03 3,290

D-ENDODONTICSD3220 THERAPEUTIC PULPOT 0 0.00 0.00 1 0.50 0.22D3330 MOLAR ROOT CANAL 0 0.00 0.00 1 2.00 0.88 50

TOTAL-ENDODONTICS 0 0.00 0.00 2 2.50 1.10 50

E-PERIODONTICSD4249 CROWN LENGTHENING 0 0.00 0.00 1 1.00 0.44 110D4341 SCAL/RT PLANING-QU 0 0.00 0.00 14 10.50 4.64 680D4345 PERIO SCALE/INFLAM 0 0.00 0.00 1 0.75 0.33 45

TOTAL-PERIODONTICS 0 0.00 0.00 16 12.25 5.41 835

F-PROSTHODONTICS (REMOVABLE)D5000 PROSTHETIC VISIT 0 0.00 0.00 1 0.00 0.00D5110 COMPLETE DENT-UP 0 0.00 0.00 3 9.00 3.98 490D5120 COMPLETE DENT-LOW 0 0.00 0.00 1 3.00 1.33 115D5214 PART CST MTL-LOW 0 0.00 0.00 1 2.00 0.88 280D5731 RELINE DENT/OFF-LO 1 0.50 3.08 1 0.50 0.22

TOTAL-PROSTHODONTICS (REMOVABLE) 1 0.50 3.08 7 14.50 6.41 885

G-ORAL SURGERYD7110 EXTRACTION-SINGLE 0 0.00 0.00 10 5.00 2.21 19D7120 EXTRACTION-ADDT'L 0 0.00 0.00 7 1.75 0.77 51D7130 ROOT REMOVAL-EXPOS 0 0.00 0.00 1 0.50 0.22D9430 OFFICE VISIT/OBSER 6 0.00 0.00 37 0.00 0.00

TOTAL-ORAL SURGERY 6 0.00 0.00 55 7.25 3.20 70

I-MISCELLANEOUSD0130 ORAL EXAM - EMERG 0 0.00 0.00 2 0.50 0.22D9110 EMERGENCY VISIT 0 0.00 0.00 3 1.50 0.66D9999 MISCELLAENOUS 1 0.00 0.00 1 0.00 0.00

TOTAL-MISCELLANEOUS 1 0.00 0.00 6 2.00 0.88

DENTAL OFFICE TOTAL 47 16.25 100.00 544 226.25 100.00 5,803

TOTAL VISITS 25 238

23ADMINISTRATIVE

PROCEDURES

MONTHLY DENTAL OFFICE STATISTICAL REPORT (MMR0450) SAMPLE: (continued)Details usage for procedures referred from the dental office to specialists.


OBSOLETE FACILITY #: VA999 SPECIALTY PROVIDER CARE


A-DIAGNOSTIC/PREVENTIVED0110 ORAL EXAM-INITIAL 1 0.25 4.35 1 0.25 0.50D0140 ORAL EVAL/PROBLEM 1 0.25 4.35 1 0.25 0.50D0150 COMP ORAL EVAL 0 0.00 0.00 1 0.25 0.50D0272 X-RAYS/BITEWING 2 0 0.00 0.00 1 0.25 0.50D0330 X-RAYS/PANORAMIC 0 0.00 0.00 6 1.50 2.99D1510 SPACE MAIN-FIX UNI 0 0.00 0.00 1 1.00 1.99 65D9310 CONSULT-GEN/SPEC 0 0.00 0.00 11 5.50 10.95

TOTAL-DIAGNOSTIC/PREVENTIVE 2 0.50 8.70 22 9.00 17.91 65

D-ENDODONTICSD3320 BICUSPID RT CANAL 0 0.00 0.00 1 1.75 3.48D3330 MOLAR ROOT CANAL 2 4.00 69.57 5 10.00 19.90 650D3347 RETREATMENT - BI 0 0.00 0.00 1 1.75 3.48

TOTAL-ENDODONTICS 2 4.00 69.57 7 13.50 26.87 650

E-PERIODONTICSD4249 CROWN LENGTHENING 0 0.00 0.00 1 1.00 1.99 110

TOTAL-PERIODONTICS 0 0.00 0.00 1 1.00 1.99 110

G-ORAL SURGERYD7110 EXTRACTION-SINGLE 0 0.00 0.00 2 1.00 1.99 19D7210 SURGICAL EXTRACTIO 1 0.50 8.70 13 6.50 12.94 270D7220 IMPACTION-SOFT TIS 0 0.00 0.00 2 1.00 1.99 120D7230 IMPACT-PARTIAL BON 1 0.75 13.04 4 3.00 5.97 172D7240 IMPACT-FULL BONY 0 0.00 0.00 3 2.25 4.48 225D7510 SURG INC & DR INTR 0 0.00 0.00 3 1.50 2.99

TOTAL-ORAL SURGERY 2 1.25 21.74 27 15.25 30.35 806

H-ORTHODONTICSD8010 ORTHO EVALUATION 0 0.00 0.00 3 1.50 2.99 120D8020 ORHT TRT PLAN & RE 0 0.00 0.00 3 3.00 5.97 450D8026 BANDING-COMPREHEN 0 0.00 0.00 1 2.00 3.98 250D8030 ORTHO THERAPY-CHLD 0 0.00 0.00 9 4.50 8.96 375

TOTAL-ORTHODONTICS 0 0.00 0.00 16 11.00 21.89 1,195

I-MISCELLANEOUSD9110 EMERGENCY VISIT 0 0.00 0.00 1 0.50 1.00

D9999 MISCELLAENOUS 1 0.00 0.00 1 0.00 0.00

TOTAL-MISCELLANEOUS 1 0.00 0.00 2 0.50 1.00

SPECIALTY PROVIDER CARE TOTAL 7 5.75 100.00 75 50.25 100.00 2,826

TOTAL VISITS 6 44

24AD

MINI

STRA

TIVE

PROC

EDUR

ES

RUN DATE 07/22/2002 CIGNA DENTAL HEALTH - PENNSYLVANIA MNMR0451 PAGE 1PA 1000001

AS OF 06/2002 MONTHLY DENTAL OFFICE ANALYSIS

DENTAL OFFICE ID: D117243 OBSOLETE FACILITY #: PA001ANALYSIS PERIOD: 01/01/2002 - 06/30/2002

LAST MONTH YEAR TO06/2001 DATE

------------- ------------TOTAL MONTHLY PAYMENTS. . . . . . . . 1,269.78 $7,401.72TOTAL PATIENT PAYMENTS. . . . . . . . $765.00 $3,686.00TOTAL SUPPLEMENTAL PAYMENTS . . . . . $6.00 $110.00TOTAL OFFICE VISIT PAYMENTS . . . . . $45.50 $462.00

------------ ------------ TOTAL DENTAL OFFICE INCOME $2,086.28 $11,660.22

============ ============

TOTAL CHAIR HOURS UTILIZED BY CDH 19.00 152.50

DOLLARS PER CHAIR HOUR $109.80 $76.46

-----------------------------------------------------------------------------------

OTHER KEY RATIOS:

CHAIR HOURS PER VISIT: 1.46 1.14

CHAIR HOURS PER MEMBER: 0.07 0.60

PERCENT OF PATIENTS WHO SELECTED YOUR OFFICE AND HAVE RECEIVED SERVICES: N/A 35.29%

-----------------------------------------------------------------------------------

# OF PATIENTS (06/2001) : 265

-----------------------------------------------------------------------------------

These statistics indicate that we may not be receiving Encounter Forms(Blue Sheets) for all CDH patients seen in your office. As a result, thismanagement report may reflect inaccurate data, and may not provide to youthe valuable information we hoped it would.

CIGNA DENTAL HEALTH is dedicated to providing participating dental officeswith on-going dental practice management tools and techniques. Pleasecontact the network manager in your respective CDH regional office. He orshe will help you bring your statistics up-to-date.

MONTHLY DENTAL OFFICE ANALYSIS (MMR0451) SAMPLE:

Lists month-to-month and year-to-month income data and key statistical information for your office.

25SPECIALTYREFERRAL

GUIDELINES

SpecialtyReferral

Guidelines

Network general dentists are

expected to render the range of

services that are required for

graduation from dental school,

including root canal therapy,

some extractions, treatment of

gingivitis and early

periodontitis, and pediatric

dentistry. Further clarifications

are discussed in each of the

specialist guidelines that follow

in this manual.

Referrals to network

specialists are indicated when

the procedures necessary for

treatment are beyond your

range of clinical skills. We have

contracted with endodontists,

periodontists, oral surgeons,

pediatric dentists and

orthodontists to provide

necessary specialty services to

members at negotiated fees.

All guidelines are subject to

state-specific and federal

guidelines.

Referral to a Network Specialist• Any referral to a network

specialist must be consistentwith a complete treatmentplan that you develop andcommunicate to thepatient/member.

• We will authorize paymentto a non-network specialistonly when there is nonetwork specialist within a 25-mile radius from themember’s home. Please call Member Services forapproval prior to sending the patient to any non-network specialist.

• We will send you monthlyupdates of the networkspecialist list.

• For more details, please refer to the referral processand treatment guidelines foreach specialty.

• Network general dentistswho refer to specialistswithout following thereferral guidelines of CIGNADental may be responsiblefor payment to the specialist.

26

Specialty Referral Guidelines (continued)

Referral Process forBoth Emergency and Non-EmergencyConditionsIt is the responsibility of theNetwork General Dentist to:• Verify member eligibility by

calling 1.800.DIAL CDH(1.800.342.5234)

• Complete the REFERRING DR. information on thereferral form.

• Indicate both the specificdiagnosis and the rationalethat requires the skills of aspecialist on the referral form.

• Have the member completethe CONTRACT HOLDERinformation on the referral form.

• Sign, and have the membersign the referral form.

• Either mail to the specialist or give the completed referralform PLUS the appropriateradiographs (and periodontalcharting, if applicable) to the patient.

• Instruct the member tocontact the specialist toschedule an appointment.

TELEPHONIC REFERRAL(emergency conditions)In situations of a dentalemergency, if a network generaldentist determines the neededtreatment is beyond their scopeand it is prudent to refer thepatient to a specialist, thenetwork general dentist should:

• Evaluate the member’sproblem with an examinationand appropriate radiograph(s).

• Call CIGNA Dental (1.800 DIAL.CDH) for areferral number and refer the member to the network specialist for an evaluation only.

• Provide the patient with awritten referral, indicating thespecific diagnosis, and provideall necessary radiographs tothe patient.

• The network specialist willobtain necessary approvals for actual treatment to be performed.

DIRECT REFERRAL(non-emergency conditions)• All referrals for non-emergency

conditions can be sent directlyto the network specialist for an evaluation and treatmentplan and do not require a referral number or writtenauthorization from CIGNADental.

• Provide the patient with awritten referral, indicating thespecific diagnosis, and provideall necessary radiographs to the patient.

• For endodontists, certaintreatments can be performedwithout the endodontistobtaining prior authorization by CIGNA Dental. This isclarified in the EndodontistSpecialist Manual.

• For periodontists, oral surgeons, orthodontists, andpediatric dentists, the specialistwill submit their treatment plan for approval prior tobeginning treatment.

• For more details, please refer to the referral process andtreatment guidelines for each specialty.

SPEC

IALT

YRE

FERR

ALGU

IDEL

INES

27

AuthorizationLimitations• Pre-authorization from

CIGNA Dental is valid for aperiod of 90 days from thedate of initial authorization.Extension of time may be granted by calling theProvider Service Organizationat 1.800.DIAL.CDH andproviding the details of the extension.

• All authorizations are subjectto plan limitations, exclusionsand guidelines for coverage.

• The specialist will receive adetailed Explanation ofBenefits that will explain any limitations for therequested authorization.

Referral to a Network EndodontistFor endodontic services thatrequire the skills of a specialist,you can refer directly to thenetwork endodontist fortreatment. Routine root canaltreatment is expected to beperformed by the networkgeneral dentist.

Refer to the section entitledReferral Process on page 26, and provide the member withboth a specific referral and allnecessary radiographs.

Please be specific in yourdiagnosis to the endodontist.Indicate the rationale thatrequires the skills of a specialist.Include which teeth you wanttreated and indicate any teeththat you have treatment plannedfor eventual extraction.

If the network general dentistrefers a patient for anyendodontic service(s) that are considered to be within the range of a network generaldentist’s clinical skills andexpertise, a backcharge may be generated by CIGNA Dentalin the amount equal to the specialist’s fee less any patient charge for the service(s)in question.

Referral to a Network PeriodontistFor periodontal services thatrequire the skills of a specialist,you can refer directly to thenetwork periodontist for an evaluation.

Refer to the section entitledReferral Process on page 26, and provide the member with a specific referral, completedperiodontal charting and amounted, recent full mouthseries of dental radiographs.

Please be specific in yourdiagnosis to the periodontist.Include which teeth you wanttreated and indicate any teeththat you may have treatmentplanned for eventual extraction.

If the network general dentistrefers a patient for anyperiodontal service(s) that areconsidered to be within therange of a network generaldentist’s clinical skills andexpertise, a backcharge may be generated by CIGNA Dental in the amount equal to the specialist’s fee less anypatient charge for the service(s)in question.

Continued on next page…

SPECIALTYREFERRAL

GUIDELINES

Referral to a Network Periodontist (continued)The general dentist should beable to identify, throughstandard examinationtechniques, the periodontalstatus of the patient and shouldbe prepared to utilize a varietyof treatment options to care forperiodontal patients.

When periodontal chartingshows pocket depths within a 3-4mm range, the generaldentist is expected to treat the patient.

When periodontal chartingshows pocket depths of 5mmor greater, it is appropriate for the patient to be seen by the periodontist.

When periodontal chartingshows progressive loss ofattached gingiva, it isappropriate for the patient to be seen by the periodontist.

28


Referral to a NetworkOral SurgeonFor oral surgical services thatrequire the skills of a specialist,you can refer directly to thenetwork oral surgeon for an evaluation.

Refer to the section entitledReferral Process on page 26, and provide the member with a specific referral and allnecessary radiographs.

Please be specific in yourdiagnosis to the oral surgeon.Include which teeth you wanttreated and indicate any teeththat may be treatment plannedfor other services. The CIGNAreferral process should not befollowed for services that are notcovered by this dental plan, suchas dental implants, orthognathicsurgery, or the extraction of thirdmolars solely for orthodonticreasons. Consultations for suchservices will not be covered.

If the network general dentistrefers a patient for any oralsurgical services that areconsidered to be within therange of a network generaldentist’s clinical skills andexpertise, a backcharge may be generated by CIGNA Dental in the amount equal to the specialist’s fee less anypatient charge for the service(s)in question.

The following services areconsidered to be within theexpected range of a networkgeneral dentist’s clinical skills and expertise and are theresponsibility of the networkgeneral dentist:• Uncomplicated routine

extraction of three (3) teeth or less.

• Routine surgical extraction ofa single tooth

• Minor surgical procedures

SPEC

IALT

YRE

FERR

ALGU

IDEL

INES

29

Benefits are allowed for theextraction(s) of impacted teeth,for the following pathologicconditions:• Non-eruption related infection

• Non-restorable caries

• Expansile odontogenic cyst or tumor

• Periodontal disease associatedwith the impaction

• Resorption of the adjacent tooth

• Pre-radiation therapymanagement

• Chronic infection, such asrecurrent pericoronitis

• Pre-prosthodontic treatment

Benefits are not allowed for theextraction(s) of impacted teeth,for the following conditions:• Prophylactic/ elective removal,

including tooth buds

• Lack of eruptive space

• Non-specific pain

• Pain due to eruption

• Headaches

Benefits for the surgicalextraction(s) of erupted thirdmolars are not allowed solely for orthodontic purposes.

Referral to a Network Pediatric DentistIf the network general dentist isunable to treat a child under theage of seven (7), the networkgeneral dentist can refer the childdirectly to the network pediatricdentist for the initial exam,radiographs, prophylaxis, andfluoride treatment. The PediatricDentist must submit forpreauthorization from CIGNADental for all other services.

Refer to the section entitledReferral Process on page 26, and provide the member witha specific referral and allnecessary radiographs that you have already taken.

Once the child, under the age of7, has been referred to be treatedby a pediatric dentist, the referralis valid until the child reacheshis/her 7th birthday, with thatsame pediatric dentist.

If the child, under the age of 7,changes to a different pediatricdentist, a new referral is needed.

CIGNA Dental will notgenerally authorize paymentfor care for children sevenyears and older who arereferred to the specialist forbehavior management only.Referrals to a Pediatric Dentistfor the sole reason ofbehavioral problems will notbe covered and the memberwill be responsible for thePediatric Dentist’s usual andcustomary fees.

If a child, age 7 or older, has amedical condition or disabilitythat prevents delivery of carein a general dental setting, aspecial consideration for ageextension of coverage will beevaluated. A letter from thepatient’s medical doctor isrequired, detailing the basis for the need of a specialty care setting.

SPECIALTYREFERRAL

GUIDELINES

30

Referral to aNetwork OrthodontistIt is the responsibility of thenetwork general dentist toevaluate and determine if there is a need for orthodontictreatment. For orthodonticservices which require the skillsof a specialist, you can referdirectly to the networkorthodontist for an evaluation.

Refer to the section entitledReferral Process on page 26, and provide the member with a specific referral and allnecessary radiographs that you have already taken.

CIGNA Dental will generallyprovide coverage for:• Fixed or removable

appliances for interceptiveorthodontic treatment

• Fixed appliance therapy for comprehensiveorthodontic treatment.

The CIGNA referral processshould not be followed forservices that are not covered bythis dental plan, such as:• Fixed or removable appliances

to guide minor toothmovement, e.g. uprighting of amesioangular molar, minorcorrection of a crossbite, orclosure of a diastema space.

• Fixed or removable appliancesto correct harmful habits, e.g. tongue thrust or thumb sucking.

• Removable appliance or otherappliances which could beconsidered as removable, as a part of comprehensivetreatment. This would include removable aligners,such as Invisalign.

Any additional costs or charges for ceramic brackets, clear brackets, lingual brackets, or other cosmetic appliances would be the member’s financial responsibility.

SPEC

IALT

YRE

FERR

ALGU

IDEL

INES


31

ProfessionalGuidelines

and QualityReview

Professional StandardsCIGNA Dental is committed toensuring the highest level ofprofessional services consistentwith accepted professionalstandards of care.

The Dental Facility

GENERAL OFFICE APPEARANCE AND ACCESSThe exterior and common areas ofthe dental office structure shouldbe well maintained and the accessto the facility and parking shouldbe adequate. Emergency exitsshould be accessible and wellmarked. The entire office,treatment areas and restroomsshould be clean and uncluttered.There should be reasonableaccommodations for handicappedand disabled persons. Allequipment should be in goodworking order.

STERILIZATION AND INFECTION CONTROLCIGNA Dental expects all dentistsand staff to comply with theCenters for Disease Control (CDC)guidelines, Occupational Safetyand Health Administration(OSHA), as well as all state andlocal regulations for theprevention and transmission ofcommunicable diseases.Specifically, all dentists andclinical staff should:

• Adhere to Universal Precautionsbased upon the generallyaccepted principle that allpatients must be treated as ifthey were infected with abloodborne pathogen. Universal Precautions includethe following:

- Follow work practice controlssuch as safe recappingtechniques for needles andwashing hands.

- Wear personal protectiveequipment such as gloves,protective gowns or jacketsand face shields.

- Maintain care in the use and disposal of “sharps”,including needles, scalpelblades and broken glass.

- Report all exposure incidents according to OSHA guidelines.

• Minimize the chance of crosscontamination by protectingpatients and staff frominfectious contact withbloodborne pathogens andairborne contaminants bycomplying with currentguidelines for disinfection andsterilization of instruments andequipment that should includethe following:

- Provide a written sterilization plan.

- Separate the areas wherecontaminated items arepresent from the areas wherethe instruments are clean.

Continued on next page… PROFESSIONALGUIDELINES ANDQUALITY REVIEW

32

Professional Guidelines and Quality Review (continued)

The Dental FacilitySTERILIZATION AND INFECTION CONTROL(continued)

- Keep the ultrasonic cleanerscovered when in use.

- Sterilize all items usedintraorally after each use orproperly dispose ofdisposable instruments.

- Store sterilized instrumentsin the same sealedcontainers, bags or cassettesthat they were packaged inprior to placing them intothe autoclave. The packagingpreserves the sterile status ofthe item until it is used onthe patient.

- Use process indicators todemonstrate that theinstruments were processedthrough heat sterilization.

• Biological monitoring, “SporeTesting”, of each autoclave orheat sterilization device isrecommended weekly andrequired at a minimum once amonth unless state regulationsmandate otherwise.

• When items are disinfected inEPA approved disinfectantsolutions, they should besoaked following thedirections of the manufacturer.A log book should bemaintained to demonstratethat the solution was activeand chemicals changedaccording to themanufacturer’srecommendations.

• Environmental surfaces should be appropriatelydisinfected and disposablecovers properly discarded.

• Provide dental laboratoryinfection control by rinsingand disinfecting impressionsand prosthetic devices,sterilizing burs and rag wheels,and changing pumice aftereach use.

• Have a current Hepatitis Bvaccination or an employee’swritten waiver declining.

• Compliance with all acceptedlocal, state and federalstandards with regards tobloodborne pathogens in thetreatment of patients and theprotection of dental staff.

RADIOLOGY SAFETYWe expect all dentists and staff to comply with CIGNA Dental,Occupational Safety and HealthAdministration (OSHA), USDepartment of Health andHuman Services (HHS), as well as state and local regulatoryagencies guidelines for radiology safety for patients and staff. CIGNA Dentalrecommends the followingradiation safety measures:• Ensure that radiation

protection items used forpatients include lead aprons that allow for proper thyroid protection.

• Monitor appropriate personnelto determine acceptable levelsof radiation exposure. This is astate-specific regulation.

• Provide proper documentationand posting of state-specificradiation safety posters.

• Ensure that radiographicequipment is in good working order, well-maintained and certifiedaccording to specific local,state and federal regulations.

ENVIRONMENTAL SAFETYWe expect all dentists and staff tocomply with CIGNA Dental’sOccupational Safety and HealthAdministration (OSHA),Environmental Protection Agency(EPA), US Department of Healthand Human Services (HHS), aswell as specific state and localenvironmental safety regulationspertaining to patients and staff.Federal OSHA regulations includethe following:• Maintain an in-office

hazardous communicationprogram including:

- A written, hazardouscommunication manual.

- Employee orientation andtraining in handling anddisposing of hazardouswaste, including mercury,developer and fixer, “sharps”and disinfectants.

- Current Material Safety DataSheets (MSDS) for allmaterials used in the office.

• Provide the proper protectivemeasures including:

- Use of masks, gloves, andprotective eyewear.

- Heavy-duty gloves to beworn while disinfectingtreatment areas andhandling instruments duringthe sterilization process.

- Eye wash equipmentaccording to state regulations.PR

OFES

SIONA

LGU

IDEL

INES

AND

QUAL

ITY R

EVIEW

33

- Proper ventilation of chemicals.

- Laboratory jackets and coats,or disposable protectiveclothing. These should beappropriately laundered ordisposed of according to statespecific regulations.

• Provide special “sharpscontainers” and dispose of themaccording to state regulations.

• Have Hepatitis B (HBV)vaccination for all staff or awaiver of refusal.

• Adhere to accepted mercurysafety recommendations

- Use of pre-measured amalgamcapsules is preferred.

- Scrap amalgam or bulkmercury should be storedunder an appropriate liquid within a sealedunbreakable container.

- Mercury spill kit is highly recommended.

• Provide a Nitrous Oxide recovery system (scavenger unit) if nitrous oxide is used in the office.

Medical EmergencyPreparednessWe expect dentists, as healthcare providers, to be prepared toprevent, recognize and properlymanage medical emergenciesthat may occur in a dentaloffice setting. Citing theCouncil on Scientific Affairs ofthe American DentalAssociation, Office Emergenciesand Emergency Kits, March 2002, includes the following:• According to the ADA

Council on Scientific Affairs examples of common emergenciesinclude, seizures,cardiovascular andrespiratory distress, altered consciousness, chest pain and drug-related emergencies.

• All doctors and appropri-ate office staff should possess current BLS/CPR certification.

• Periodic office emergencydrills are encouragedincluding a well definedprotocol for activating theEMS system.

• Telephone numbers of EMSand other appropriatelytrained health care providersshould be posted.

• The office should have readilyavailable emergency drug kitand the skills to properly useall of the items it containsand/or a plan to handlemedical emergencies. Thedrugs should be current andnot outdated.

• The content of the kit is up toeach individual dentist butshould follow the currentrecommendations of the ADACouncil of Scientific Affairs.

• Portable oxygen that can beadministered under positivepressure should be able to bedelivered to any location inthe facility.

• Consult the ADA, specialists’associations, and state specificmedical, dental and pharmacyboards for emergency drugsand requirements for dentistsand dental specialists using allmodalities for producing statesof analgesia, sedation, andgeneral anesthesia.

PROFESSIONALGUIDELINES ANDQUALITY REVIEW

34

The PatientRecord/FileIn accordance with professionallyrecognized standards of dentalpractice and as part of ourQuality Management Program,we expect each network generaldentist to follow the DentalRecord Guidelines listed below.

DENTAL RECORD GUIDELINESAll guidelines are subject to statespecific and federal regulations.

INTRODUCTIONThe patient record should be anorderly, standardized, legibledocument. The record should bewritten in ink or it can consisttotally of electronic images. Patient records should conformto the following requirements:• Each patient should have an

individual patient record/file.

• The same type of patientrecord should be used for allpatients in the practice.

• Confidentiality of the patientrecord is protected by theHealth Insurance Portabilityand Accountability Act(HIPAA) of 1996, withrequirements in effect in 2003.

• Members who wish totransfer to another dentaloffice are entitled to asummary or copy of theirrecord and copies of theirradiographs at no charge to them.

• If a hard copy record iskept, the record shouldprovide for appropriatestorage of all forms andradiographs.

• Radiographs must be ofappropriate content,diagnostic in quality,mounted and properlyidentified with patientname and date taken, andreadily accessible in therecord/file.

Quality of Patient CareWe expect dentists, as health careproviders, to consistently providean acceptable level of patient care, including evaluation anddiagnosis, treatment planning,treatment rendered, and treatment outcomes.

Diagnosis must be based on athorough evaluation, withsufficient information to identifysignificant clinical problems.

Treatment planning must beappropriate to the needs of the patient.

Treatment rendered must beprevention-oriented, properlyprioritized, timely and of goodtechnical quality.

On-Site ReviewCIGNA Dental Care network dental offices must participate inthe Quality Management Program,through scheduled, periodic on-site office reviews.

This audit program is designed tosuggest improvement opportunitiesin the dental practice as well asensure the highest quality of careto the involved patients.

A sample of the forms used in thisprocess appear on page 35.

PROF

ESSIO

NAL

GUID

ELIN

ES A

NDQU

ALITY

REV

IEW

35

Dental

CIGNA DENTAL INITIAL QUALITY ASSESSMENT – FACILITY REVIEW FORM SAMPLE: (side 1)

CIGNA DENTALINITIAL QUALITY ASSESSMENT

FACILITY REVIEW FORM

OFFICE NUMBER: OFFICE NAME:

REVIEW DATE: REVIEWER’S NAME:

Check “A” (Acceptable), “U” (Unacceptable), or “N/A” (Not Applicable) for every item in each question

A. General Office Appearance:

A U N/A1. Exterior and common areas of the building are well maintained?

2. Office, treatment rooms and restrooms are clean and uncluttered?

3. Equipment is in good working order?

4. Emergency exits are accessible and well marked?

B. Sterilization and Infection Control:

A U N/A1. All items used intra-orally are appropriately sterilized after each use and staff trained in

sterilization and infection control procedures and protocols? (CA – protocols must beconspicuously posted)

2. Items sterilized in EPA-approved disinfectant solutions for recommended time permanufacturer’s guidelines? Solution changed at recommended intervals?

3. Environmental surfaces are appropriately disinfected with EPA-approved solutionbetween patients and at the end of the day?

4. Gloves and mask worn? Gloves changed between patients?

5. Documentation indicates that biological test of heat sterilization (spore testing)performed monthly (AZ and CA – performed weekly)?

6. Sterilized instruments are stored in sealed containers, bags, wraps or appropriate traysprior to use?

7. Disposable film holder devices are used or reusable devices sterilized or disinfectedbetween use?

8. Disposable instruments properly disposed?

9. Disposable covers properly disposed?

10. If laboratory pumice is used in office, is pumice changed after each use?

11. Laboratory Ragwheels and Laboratory burs sterilized?

36

A U N/A12. Impressions rinsed and disinfected prior to delivery to laboratory?

13. Sharps properly disposed of in appropriate sharps container?

14. Laboratory jackets/coats or disposable protective clothing worn?

15. Laboratory jackets/coats appropriately laundered or disposed?

16. Protective eyewear worn?

17. Ultrasonic cleaners used and kept covered during use?

C. Emergency Occupational and Environmental Safety:

A U N/A1. Portable oxygen tank that can be delivered under positive pressure available?

2. If an Emergency kit is present, the items are current? The content of the kit is up to eachindividual dentist, as recommended by the ADA council on scientific affairs. If kit is notpresent, then mark evaluation n/a.

3. Plan to handle medical emergencies is present in office? Note: If office protocol entailsonly calling 911, then this question does not apply and evaluation should be marked n/a.

4. Emergency telephone numbers posted (for example: 911, fire, and ambulance)?

5. Lead apron, which allows for proper thyroid protection used?

6. Hepatitis vaccination available for clinical staff in office, or a waiver signed?

7. Dentist and appropriate staff have current CPR certification?

8. If mercury is used in office, does mercury hygiene include use of pre-measured amalgamcapsules? Amalgamators covered? If bulk mercury is used: Stored in sealed, unbreakablecontainers and mercury spill kit available?

9. If nitrous oxide is used in office, is nitrous oxide recovery system (scavenger unit)employed in office?

10. Blood pressure cuff/sphygmomanometer in office?

D. Operations:

A U N/A1. Adult prophylaxis time adequate?

2. Continuity of Care: Recall System?

3. Dental hygiene staff are certified and licensed per state regulations?

4. Diagnostic imaging machines are registered and inspected according to state law?

Facility Comments:

CIGNA DENTAL INITIAL QUALITY ASSESSMENT – FACILITY REVIEW FORM SAMPLE: (side 2)

37CIGNA DENTAL QUALITY ASSESSMENT – PATIENT RECORD REVIEW FORM SAMPLE: (side 1) SAVE AND COPY AS NEEDED:

Dental

CIGNA DENTALQUALITY ASSESSMENT

PATIENT RECORD REVIEW FORM

OFFICE NUMBER: OFFICE NAME:

REVIEW DATE: CONSULTANT NAME:

MEMBER ID: MEMBER NAME:

1.

2.

3.

4.

5.

I. DOCUMENTATION

A. Medical History

1. Comprehensive information collection General medical history with information pertaining to general health and appearance, systemic disease, allergies and reactions to anesthetics. Should include a list of any current medications and/or treatment. Proactive format is recommended. Name, telephone number of physician and person to contact in an emergency. Patient must sign and date all baseline medical histories.

2. Medical follow-up Patient comments. DDS notes, or consultation with a physician should be documented in the chart.

3. Appropriate medical alert Should be uniform and conspicuously located on the portion of the chart used during treatment and should reflect current history.

4. Doctor signature and date Dentist must sign (or initial) and date all baseline medical histories after review with patient.

5. Periodic update Documentation of medical history updates at appropriate intervals. Must be signed by the patient and the provider. Acceptable on medical history form or in the progress notes. Should reflect changes or no changes. Recommend updated to be done annually.

B. Dental History/Chief Complaint

1. Chief complaint Documentation of chief complaint and pertinent information relative to patient’s dental history.

C. Documentation of Baseline Intra/Extra Oral Examination

1. Status of teeth/existing conditions Grid or a narrative of existing conditions (existing restorations, missing teeth, impactions, caries, open or overhanging margins, open contacts, pathology).

2. TMJ/Occlusal evaluation Evidence of TMJ exam and evaluation of occlusion should be determined.

3. Prosthetics Evaluation of existing appliance(s), teeth replaced, clasps, etc.

4. Status of periodontal condition a. Condition of gingival tissue, calculus, plaque, bleeding on probing, etc.b. Evidence of baseline probing should be documented.

5. Soft tissue/oral cancer exam a. Evidence that oral cancer exam was done (recorded at initial and recall exams).b. Note of any anatomical abnormalities.

D. Progress Notes

1. Legible and in ink Provider should be reminded that written or electronic progress notes are a legal document. Written notes should all be in ink and legible. Corrections should be made by lining-out.

2. Documentation detail Dental treatment progress notes should be in detail. Documentation of any follow-up instructions to the patient or recommendations for future care. Appropriate follow-up for complications.Documentation of patient leaving the practice and reasons, if known. Broken appointment follow-up documented. Documentation if any records forwarded, etc.

3. Signed and dated by provider All entries must be signed or initiated and dated by the treating provider.

4. Anesthetics Notation in progress notes as to the type and amount of anesthetics used; or notation “no anesthesia used” for applicable situations.

5. Prescriptions Medications prescribed for the patient are documented and signed, Rx and Dsp, in the progress notes or copies of all prescriptions are kept in the chart. Note an Rx given on phone. Recommended that dental lab prescriptions be documented in the progress notes or a copy kept in the chart.

II. QUALITY OF CARE

A. Radiographs

1. Quantity/frequency a. Adequate number of radiographs to make an appropriate diagnosis and treatment plan, per FDA guidelines.

b. Recall x-rays should be based on FDA guidelines. Depends on complexity of care, caries susceptibility, amount and type of treatment and time since last exposure.

c. Whenever possible, radiographs should not be taken if recent acceptable films are available from another source.

d. Any refusal of radiographs should be documented.

2. Technical Quality a. Lack of overlapping contacts, and cone cuts that affect diagnostic value; periapical films should show apices.

b. Good contrast, not over-/under-developed; no chemical stains.

3. Recall Recent radiographs must be mounted, labeled and dated for reviewing and comparison with past radiographs. If films are scanned into a computer, they are assigned to correct patient and dated.

38 CIGNA DENTAL QUALITY ASSESSMENT – PATIENT RECORD REVIEW FORM SAMPLE: (side 2) SAVE AND COPY AS NEEDED:

B. Treatment Plan

1. Present and in ink a. Comprehensive documentation of patient needs and treatment recommendations, all documentation in ink or in electronic format.

b. Consistent with diagnosis and clinical exam, and corresponds with treatment rendered.c. Alternative treatment plans should be documented.d. Consultations and referrals should be noted when necessary.e. Chief complaints treated.

2. Sequenced Case should be sequenced in order of need and consistent with diagnostic and examination findings, and in compliance with recognized accepted professional standards. A possible sequence follows:a. Relief of pain; discomfort and infection.b. Prophylaxis and instructions in preventive care.c. Treatment of extensive caries and pulpal inflammation. Endodontic therapy.d. Periodontal treatment.e. Replacement of missing teeth, or restorative treatment.f. Placement of patient on recall schedule with documentation of progress notes.

3. Informal consent a. Documentation that treatment plan has been reviewed with the patient and that the patient understands the risks, benefits and alternatives to care.

b. Patients financial obligation for treatment plan is documented.c. An appropriate form signed by the patient or guardian. Documentation that all patient’s

questions were answered. Consent signed by dentist.d. Documentation of any refusal of recommended care.

III. TREATMENT OUTCOME OF CARE

A. Preventive Services

1. Diagnosis Documentation that prophylaxis was performed in a timely manner. Documentation of fluoride treatments, as appropriate to age of patient and caries incidence. Evidence of periodic Soft Tissue Exam and Perio screening performed.

2. Oral hygiene instructions Documentation of instructions given to patient.

3. Recall Documentation of timely recall of patient (mark n/a if treatment is ongoing).

B. Operative Service

1. Diagnosis Recall and past radiographs used to evaluate the need for treatment. Treatment performed in a timely manner.

2. Restorative outcome and follow-up a. Margins, contours, and contacts appear radiographically acceptable.b. Prognosis good for appropriate longevity. Minimal subsequent unplanned treatment. Unplanned

treatment-redo of recent restorations due to fracture, extraction, RCT, etc.

C. Crown and Bridge Services

1. Diagnosis Recall and past radiographs used to evaluate the need for treatment. Treatment performed in a timely manner.

2. Restorative outcome and follow-up a. Margins, contours, and contacts appear radiographically acceptable.b. Prognosis good for appropriate longevity. Minimal subsequent unplanned treatment. Unplanned

treatment-redo of recent restorations due to fracture, extraction, RCT, etc.

D. Endodontic Services

1. Diagnosis Evidence that pocket markings and radiographs are available to determine level of treatment needed. Treatment performed in a timely manner.

2. Rubber dam use Evidence of rubber dam use on working x-rays and/or documentation in progress notes.

3. Endodontic outcome and follow-up a. Radiographic evaluation of treatment to determine that canal(s) is/are properly filled and wellcondensed (final radiographs).

b. Prognosis good for appropriate longevity. Minimal subsequent unplanned treatment, extraction of recently completed endo.

c. Documentation of final restoration.d. Recall follow-up recommend with PA x-ray.

4. Specialist referral Referral to a specialist in appropriate circumstances and in a timely manner documented.

F. Prosthetic Services

1. Diagnosis Evaluation of form, fit, and function of existing prosthesis. Evaluation of need where no prosthesis exists. Treatment performed in a timely manner.

2. Prosthetic outcome and follow-up a. Treatment was done in a timely manner, including adjustments.b. Prognosis good for appropriate longevity.

G. Surgical Services

1. Diagnosis Radiographic and/or soft tissue exam supports treatment rendered. Treatment performed in a timely manner.

2. Surgical outcome and follow-up a. Comprehensive documentation of treatment done, materials used, and any noteworthy occurrencesduring the procedure.

b . Documentation of post-operative instructions to patient.c. Documentation of any needed post-operative care, including suture removal.

3. Specialist referral Referral to a specialist in appropriate circumstances and in a timely manner documented.

IV. OVERALL PATIENT CARE AND OUTCOME

Please indicate either “yes” or “no” Yes No a. Is overall care and outcome satisfactory? If no, please provide specifics. Report separately to theto the following two questions Dental Director.

Yes No b. Significant quality issue exists to a degree that requires Dental Director review. Give specifics.

TO ORDER SUPPLIES:

FAX YOUR ORDER TO:CIGNA Dental

c/o Moore Wallace1.800.632.9234)

OR MAIL TO:CIGNA Dental

c/o Moore Wallace1750 Wallace AvenueSt. Charles, IL 60174

1.800.342.5234

Include your office number,name, address, phone number,

supplies needed, catalog number,and quantity needed.

We’re listening.Talk to us.The dental marketplace iscontinuously changing.We want to hear yourcomments and ideas.

Contact the ProviderService Organizationto share your thoughtsat 1.800.DIAL.CDH.

CIGNA Dental refers to the following operating subsidiaries of CIGNA Corporation: Connecticut General Life Insurance Company and CIGNA Dental Health,Inc., and its operating subsidiaries. The CIGNA Dental Care plan is provided by CIGNA Dental Health Plan of Arizona, Inc., CIGNA Dental Health of California,Inc., CIGNA Dental Health of Colorado, Inc., CIGNA Dental Health of Delaware, Inc., CIGNA Dental Health of Florida, Inc., a Prepaid Limited HealthServices Organization licensed under Chapter 636, Florida Statutes, CIGNA Dental Health of Kansas, Inc. (Kansas and Nebraska), CIGNA Dental Health ofKentucky, Inc., CIGNA Dental Health of Maryland, Inc., CIGNA Dental Health of Missouri, Inc., CIGNA Dental Health of New Jersey, Inc., CIGNA Dental Healthof North Carolina, Inc., CIGNA Dental Health of Ohio, Inc., CIGNA Dental Health of Pennsylvania, Inc., CIGNA Dental Health of Texas, Inc., and CIGNA DentalHealth of Virginia, Inc. In other states, the CIGNA Dental Care plan is underwritten by Connecticut General Life Insurance Company or CIGNA HealthCareof Connecticut, Inc. and administered by CIGNA Dental Health, Inc.

CAT# 569023c 7/05

cigna dental care...4 benefits for network dentists source of patients by participating in the cigna...

Documents