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2017Provider ManualThis document contains proprietary andconfidential information and may not bedisclosed to others without writtenpermission.Publication: January 2014Revised: June 2017www.argusdentalvision.comService Area: FloridaProvider Services Number: 888.779.3566
QUICK REFERENCE LISTREFERENCETelephone #Fax #Email AddressArgus Provider dentialing@argusdentalvision.comArgus Credentialingportal.argusdentalvision.comProvider PortalArgus Customer Care813 864-0625877 864-0625Argus AppealArgus Pre-Service AppealArgus Pre-treatment(Standard) 3-283- com813-283-2441813-283-2412Argus omArgus gus dentavision.comArgus SIU: Fraud, Waste, lvision.com
Table of ContentsI. Introduction . 4II. Member and Provider Rights . 5III. Plan Eligibility and Member ID Cards . 7IV. Services. 9General Exclusions . 10Limitations. 11Diagnostics .11Restoratives .11Endodontics .12Periodontics .12Prosthodontics .13Oral Surgery .14Orthodontics .14Non-Covered Services .15V. Referral Process .15VI. Claims .20Pretreatment Review . 20Claims Submission . 20Coordination of Benefit. 23Filing Limit . 23Explanation of Benefit . 23Claims Appeal Process. 23VII. Professional Standards .24Provider Roles & Responsibilities. 25Provider Prohibited Activities . 26Patient Record. 27Sterilization and Infection Control . 31Medical Emergencies. 31Dental Emergencies. 32Radiology. 33Radiology Table . 36VIII. Quality Improvement Program .37Credentialing . 37Medicaid Provider Eligibility . 38IX. Provider Rights .39 2015 Argus Dental & Vision, Inc., Proprietary & Confidential2
Discipline and Termination of Participating Dentist . 39Peer Review Process . 40Initial Site Reviews . 40Dental Record Reviews . 41Utilization Management . 41Member Satisfaction Surveys . 42Complaint Monitoring and Trending . 44Quarterly Quality Indicator . 46X. Compliance . 46HIPAA . 46Website Links to Online HIPAA Resources . 47FWA . 48Recall System Verification. 48XI. Cultural Competency Program .50XII. Plan Design Schedules .51XIII. Risk Management .51Forms:Adverse Incident.53Risk Management Use .55Specialty Referral Form .56 2015 Argus Dental & Vision, Inc., Proprietary & Confidential3
I.IntroductionArgus Dental & Vision, Inc. is licensed through the Florida and Texas Department of Insurance as a PrePaid Limited Health Service Organization (PLHSO), Third Party Administrator (TPA), Discount MedicalPlan Organization (DMPO), and a New York Independent Practice Association. Founded by a Floridadentist to provide dental and vision benefits that offer value and quality to members, Argus is ownedand operated by professionals with extensive experience in the insurance and health care industries.The total executive and management experience combines over one hundred years of industryknowledge with an excellent historical record of successful, benefit implementation for millions ofmembers.Dental Benefits: Argus has built one of the largest proprietary dental networks with a nationalpartnership in all fifty states in the United States. Our network of partnering dentists continues to growat a rapid rate and currently offers members their choice of dentists from over 100,000 combinations ofpartnering general and specialty locations. Argus Dental & Vision, Inc. is the first dental plan organizationin the United States to be accredited for quality care by the Accreditation Association for AmbulatoryHealth Care (AAAHC) and is contracted with the Florida Healthy Kids Corporation to provide affordabledental care to children in Florida. All Argus dentists are credentialed in accordance with guidelines setforth by the National Committee for Quality Assurance (NCQA) and the Centers for Medicare andMedicaid Services (CMS).Superior Service: Customer Service is of paramount importance and a key factor which differentiatesArgus from other benefit carriers. Our online enrollment, flexible payment options and immediateeligibility makes our services convenient, affordable and easy to execute.Wide Range of Quality Benefit Designs: Through collaboration with consumers, providers and agents,Argus has developed a wide-range of quality benefit plan designs with true value and affordablepremiums supported by excellent service. Argus offers benefit packages for individuals, families, largeand small employer groups, governmental agencies, large HMO Medicare/Medicaid recipients andassociations. Argus is pioneering a new era of dental insurance with the Dental Saving Account (DSA)plan, a dollar-based plan design offering better freedom of choice and minimal restrictions for patients.Strengthened by partnership with National Guardian Life and rated A Excellent by A.M. Best, Argusprovides the coverage and security expected of a premiere dental and vision benefits organization. 2015 Argus Dental & Vision, Inc., Proprietary & Confidential4
II.Member and Provider RightsFlorida law requires that health care providers and health care facilities recognize member rights whilereceiving dental care. Members have the right to request a copy of the full text of this law from theirhealth care provider or health care facility. A summary of your rights and responsibilities are as follows.A patient has the right to:1. be treated with courtesy and respect, with appreciation of his or her individual dignity, and withprotection of his or her need for privacy.2. a prompt and reasonable response to questions and requests.3. know who is providing health care services and who is responsible for his or her care.4. know what patient support services are available, including whether an interpreter is available ifhe or she does not speak English.5. know what rules and regulations apply to his or her conduct.6. be given by the health care provider information concerning diagnosis, planned course oftreatment, alternatives, risks, and prognosis.7. refuse any treatment, except as otherwise provided by law.8. be given, upon request, full information and necessary counseling on the availability of knownfinancial resources for his or her care.9. know, upon request and in advance of treatment, whether the health care provider or facilityaccepts the patient’s plan benefit coverage.10. receive, upon request, prior to treatment, a reasonable estimate of charges for health careservices.11. receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to havethe charges explained.12. impartial access to treatment or accommodations, regardless of race, national origin, religion,handicap, or source of payment.13. treatment for any emergency condition that will deteriorate from failure to provide treatment.14. know if treatment is for purposes of experimental research and to give his or her consent orrefusal to participate in such experimental research.15. express grievances regarding any violation of his or her rights, as stated in Florida law, through thegrievance procedure of the provider or facility that served him or her and to the appropriate statelicensing agency.16. to participate with the provider in making decisions about the health care he or she receives andprovide input into planned treatment.17. receive information about Argus, its services, providers and member/patients' rights andresponsibilities.18. participate with the provider in making decisions about his or her health care. 2015 Argus Dental & Vision, Inc., Proprietary & Confidential5
19. have a candid discussion about appropriate or medically necessary treatment options for yourhealth conditions, regardless of cost or benefits.20. voice complaints or appeals about Argus or the care it provides.21. make recommendations about Argus' member rights and responsibilities policies.22. receive information about advance directives, provider’s credentials and absence of malpracticecoverage.23. change providers if other providers are available.A patient has the responsibility:1. to provide to Argus and its providers, to the best of his or her knowledge, accurate and completeinformation about present complaints, past illnesses, hospitalizations, medications, and othermatters relating to his or her health.2. to report unexpected changes in his or her condition to the provider.3. to report to the provider whether he or she comprehends a contemplated course of action andwhat is expected of him or her.4. to understand his or her health problems and participate in developing mutually agreed-upontreatment goals to the degree possible.5. to follow the treatment plan recommended by the provider.6. to keep appointments and, when he or she is unable to do so for any reason, will notify theprovider or facility.7. for his or her actions if he or she refuses treatment or does not follow the provider's instructions.8. to assure the financial obligations of his or her care are fulfilled as promptly as possible.9. to follow facility rules and regulations affecting patient care and conduct.10. to inform his or her provider about any living will, medical power of attorney, or other directivethat could affect his or her care.11. to provide a responsible adult for transportation from the facility if required by the provider insituations where sedation is administered.Providers are required to provide services that are:1. Not discriminating against any patient in any manner including but not limited to:a)b)c)d)e)Source of paymentRaceEthnicityNational originSex 2015 Argus Dental & Vision, Inc., Proprietary & Confidential6
f)g)h)i)j)k)l)m)n)o)Sexual orientationAgeReligionPlace of residenceHealth statusMental or physical disabilityClaims experienceMedical historyEvidence of insurabilityGenetic information2. Preserving patient dignity and observing the rights of patients.3. Abiding by all administrative and medical policies and procedures established by Argus.4. Providing all services in a culturally competent manner and accommodating patients withdisabilities.5. Providing patients with complete information concerning their diagnosis, treatment, andprognosis and giving them the opportunity to participate in decisions involving their health care.Argus Dental & Vision, Inc., herein referred as ‘Plan’, shall disseminate bulletins as needed toincorporate any needed changes to this document.III.Plan EligibilityAny person enrolled in the Plan program is eligible for benefits under the certificate.Member Identification CardMembers will receive a plan ID card. Participating providers are responsible for verifying that membersare eligible prior to the services being rendered and to determine if recipients have other dentalcoverage. (Refer to provided examples of current plan ID cards.) Please note that due to possibleeligibility status changes, ID card information does not guarantee payment and is subject to changewithout notice. Providers are encouraged to verify member eligibility at each visit. Providers shouldrequest a picture ID to verify that the person presenting the ID card is the person named on the card. Ifproviders suspect a non-eligible person is using a member’s ID card, please report the occurrence toArgus’ Fraud and Abuse Hotline at 813.283.1276. 2015 Argus Dental & Vision, Inc., Proprietary & Confidential7
Prestige Health ChoiceFreedom Health PlanCarePlus Health PlansFlorida Healthy Kids (FHK)Optimum Health CareArgus Master PlanArgus Kid’s Choice Dental PlanArgus Choice PPO Plan 2015 Argus Dental & Vision, Inc., Proprietary & Confidential8
Argus Dental’s Eligibility SystemsThe Plan offers two options to providers needing to obtain eligibility information. Those options are thecustomer care phone line and web portal system.Customer Care LineUpon calling the Argus Dental toll-free number at 877.864.0625, select option 2 and you will be directedto an Argus customer care representative.Access eligibility information via InternetParticipating providers can access the Argus Dental & Vision Provider Portal system by logging ontohttps://portal.argusdentalvision.com and registering with their tax identification number. The portalsystem grants participating providers access to eligibility along with information pertaining to claimsand pre-determinations. The Argus Provider Portal system also allows participating providers to submitclaims and pre-determinations directly to Argus. In addition, a provider can verify a member’s eligibilitywhile accessing the portal system.1. Your first time on the website, you will need to register to gain full access to the Provider Portal.2. You may log in at the same website address as previously noted.to view patient eligibility, claiminformation, and upload your claims.Argus requires your TIN and a Payor Assigned Number for log in. After completing the registrationprocess in full you will have access to your members’ eligibility and claim information.Please note that due to possible eligibility status changes, the information provided by either systemdoes not guarantee payment.If you are having difficulty accessing the website, please contact Customer Care at 877.864.0625.Medicaid EligibilityMedicaid provides medical coverage to eligible, low-income children, seniors, disabled adults andpregnant women. Dental services are included as part of this medical coverage. The costs of Medicaid areshared by both the state and federal government. Each state operates its own Medicaid program under astate plan that must be approved by the federal Centers for Medicare & Medicaid Services (CMS).Medicaid services in Florida are administered by the Agency for Health Care Administration (AHCA).Medicaid eligibility in Florida is determined by the Department of Children and Families (DCF) or thesocial Security Administration (for SSI recipients). The Florida Medicaid Management Information System(FMMIS) is monitored by AHCA for potential members. AHCA notifies potential members of theirMedicaid eligibility.Medicaid recipients will not be discriminated on the basis of religion, gender, sexual orientation, race,color, age, national origin, health status, pre-existing condition or need for health care services. Argus 2015 Argus Dental & Vision, Inc., Proprietary & Confidential9
will not use any policy or practice that has the effect of such discrimination.IV.ServicesPlease refer to the specific plan participation for covered benefits. To receive benefits, members mustreceive care from the participating providers. Members may be assigned to a specific General Dentist’s orSpecialist’s office to receive covered benefits. For designated plans, a General Dentist or Pediatric Dentistmust submit a referral to Argus in order to have a Specialist (endodontists, oral surgeons, orthodontists,periodontists and prosthodontists) appointment scheduled and for the visit to be covered. For any otherArgus plans, the member may self-refer or be direct-referred to the specialist.General Exclusions1. Services which, in the opinion of the participating General Dentist or Specialist, are notnecessary for the patient's dental health.2. Cosmetic or experimental dental services, and/or procedures not generally performed in aGeneral Dentist office.3. Cost of hospitalization and/or pharmaceuticals.4. Any services performed by a non-participating General Dentist or non-participating Specialist.5. Services that cannot be performed because of the general health of the patient.6. Treatment which, in the opinion of the participating General Dentist, must be performed by anon-participating Specialist.7. Services which are not consistent with the usual and customary services provided by theParticipating General Dentist or Specialist.8. Any dental treatment started prior to the member's effective date.9. Any dental treatment started prior to the provider’s effective date.10. Services for injuries and/or conditions which are paid or payable under Worker's Compensationor Employer Liability Laws.11. Treatment for cysts, neoplasms and malignancies.12. Services provided without cost to the Subscriber by the government or an agency thereof, orany municipality, county and other subdivisions.13. The cost of precious metal used in any form of dental benefits.14. Any procedure not specifically listed as a covered benefit in the Schedule of Benefits.15. Cost of dental care covered under any automobile, medical or no-fault or similar type insurance.16. Fixed bridge work is not covered for some plans.17. Sealants applied to baby teeth are not covered. 2015 Argus Dental & Vision, Inc., Proprietary & Confidential10
Limitations18. Certain services must be preauthorized prior to treatment. Refer to the plan fee schedule fordetail.19. Services must be individualized, specific, and consistent with symptoms or confirmed diagnosisof the illness or injury under treatment, and not in excess of the recipient's need.20. Services must reflect the level of services that can be safely furnished, and for which no equallyeffective and more conservative or less costly treatment is available statewide.21. Services must be furnished in a manner not primarily intended for the convenience of themember, the member's caretaker, or the provider.22. Unspecified procedures are not covered without a report demonstrating services provided arecovered under the terms of the exclusions and limitations.23. Intravenous conscious sedation is limited to medically necessary covered oral surgery.Diagnostics24. Diagnostic services include the oral examination, and selected radiograph needed to assess theoral health, diagnose oral pathology, and develop an adequate treatment plan for the member'soral health. Reimbursement for some radiographs of the same tooth or area may be denied ifArgus determines the number to be redundant, excessive or not in keeping with the federalguidelines relating to radiation exposure. The maximum amount paid for individual radiographstaken on the same day will be limited to the allowance for full mouth series. For example, aPanoramic X-ray and 4 Bitewing X-rays taken in a day will be considered a Full mouth x-ray(D0210).25. Reimbursement for radiographs is limited to those films required for proper treatment and/ordiagnosis.26. All radiographs must be of good diagnostic quality, properly mounted, dated and identified withthe recipient's name and date of birth. Reimbursement for substandard radiographs will not bemade. Argus will recoup any payments that are determined to have been paid for substandardradiographs.27. Argus utilizes the guidelines published by the Department of Health and Human Services forDevices and Radiological Health.Restoratives28. Reimbursement includes local Anesthesia.29. Services are limited to essential services to restore and maintain dental health. Restoration isnot covered on primary teeth if loss is expected within six (6) months.30. Payment is made for restorative services based on the number of surfaces restored, not on the 2015 Argus Dental & Vision, Inc., Proprietary & Confidential11
number of restorative per surface, or per tooth per day. A restoration is considered a two-ormore surface restoration only when two or more actual tooth surfaces are involved, whetherthey are connected or not.31. Tooth preparation, all adhesives (including amalgam and resin bonding agents), acid etching,copalite, liners, bases, direct and indirect pulp caps, curing, and polishing are included in the feefor restoration.32. Billing and reimbursement for cast crowns and post & cores or any other fixed prosthetics shallbe based on cementation date.33. When restorations involving multiple surfaces that are outside the usual anatomical expectationare requested or performed, the allowance is limited to that of a one-surface restoration. Any feecharged in excess of the allowance for the one-surface restoration is disallowed.Endodontics34. Payment for conventional root canal therapy is limited to treatment of permanent teeth orretained primary teeth with no succedaneous permanent teeth. Endodontic therapy for primaryteeth with succedaneous permanent teeth is limited to pulpal therapy.35. Root Canal Therapy is reimbursable: a) for teeth that have restorative crowns, b) if the prognosisof the tooth is not questionable for periodontal reasons, and c) if exfoliation of a primary tooth isnot anticipated within eighteen months.36. The standard acceptability employed for endodontic procedures requires that the canal(s) becompletely sealed apically and laterally. In cases where the root canal filling does not meet Argus’treatment standards, Argus can require the procedure to be redone at no additional cost. Anyreimbursement already made for an inadequate service may be recouped after any post paymentreview. A pulpotomy or palliative treatment is not to be billed in conjunction with a root canaltreatment.37. Pulpotomies will be limited to primary teeth or permanent teeth with incomplete rootdevelopment38. The fee for root canal therapy includes diagnosis, extirpation treatment, temporary fillings,fillings and obturation of root canals, and progress radiographs. A completed fill (Final Fill)radiograph is also included.39. Filling material not accepted by FDA (e.g. Sargenti filling material) is not covered.Periodontics40. Reimbursement for periodontal procedure is limited to the most inclusive procedure if morethan one periodontal procedure is provided in the same area.41. Gingivectomies are not reimbursable when done in conjunction with crown preparation, scalingand root planing or osseous surgery, when performed on the same day. 2015 Argus Dental & Vision, Inc., Proprietary & Confidential12
42. Full mouth debridement is not reimbursable when done on the same day with comprehensiveoral evaluation(D0150) or comprehensive oral evaluation (0180)Prosthodontics43. Provision for removable prostheses when masticatory function is impaired, or when existingprosthesis is unserviceable and when evidence is submitted that indicates that the masticatoryinsufficiency is likely to impair the general health of the member.44. Approval for partial dentures to replace posterior teeth will not be allowed if there are in eachquadrant at least three (3) periodontally sound posterior teeth in fairly good position andocclusion with opposing dentition.45. Approval for cast partial dentures for anterior teeth generally will not be given unless one ormore teeth in the same arch are missing. Partial dentures are not a covered benefit when eight(8) or more posterior teeth are in occlusion.46. Dentures will not be approved when: a) dental history reveals that any or all dentures made inrecent years have been unsatisfactory for reasons that are not remediable because ofphysiological or psychological reasons, or b) repair, relining or rebasing of the patient's presentdentures will make them serviceable.47. A preformed denture with teeth already mounted forming a denture model is not a coveredservice.48. Billing and reimbursement for partials and denture shall be based on delivery date.49. Delivery of removable prostheses includes up to three (3) adjustments within six (6) months ofthe delivery for a complete or partial denture and within three (3) months of the delivery forimmediate dentures.50. No partial dentures for a single tooth will be covered unless replacing an anterior tooth.Reimbursement for an all-acrylic interim partial (Flipper) is limited to the replacement ofanterior teeth in any instance.51. Relines include all necessary adjustments for a period of six (6) months from the date of thereline. A reline using a “light-cured” technique is a chairside reline. R
Florida law requires that health care providers and health care facilities recognize member rights while receiving dental care. Members have the right to request a copy of the full text of this law from their health care provider or health care facility. A summary of your rights and respon
