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TDP Diagnostic Materials Requirements at a Glance
This is an abbreviated list of procedures
that require diagnostic materials for review. For a detailed
list of all diagnostic materials requirements by procedure
code, please click on the following link
https://secure.ucci.com/provider/diag-req
(Note: You will need a My Patients'
Benefits or Xpress Claim logon and password to access this
document).
The procedures listed below require
submission of diagnostic materials for review. Failure
to submit all the required materials will result in a claims
processing delay.
Dentists are requested to submit diagnostic materials
they used for diagnosis and treatment planning. If,
for some reason, radiographs are not available,
a brief explanation should be included on the claim form.
If submitting claims electronically, please provide a
brief explanation in the remarks field.
All radiographs submitted (including copies)
should be of diagnostic quality and mounted properly with
the left and right sides clearly marked. They should be
identified with the dentist's name and address,
the patient's name and identification number and the
date the radiographs were taken. Duplicate radiographs
will only be returned upon request from the dental office.
Note: The requirement for providers to
submit radiographs and other clinical documentation may be
relaxed by United Concordia Companies, Inc. (UCCI)
for those participating providers that have been
selected to participate in UCCI's HONORS program.
** Crowns, Inlays, Onlays,
Buildups, Post & Cores
Pretreatment periapical
Incomplete Endodontic Treatment
Pretreatment periapical
Any working films, and
Narrative (describe treatment provided and why it
could not be completed)
Internal Repair of Perforation Defect
Pretreatment periapical, and
Narrative (describe patient's condition
and treatment provided)
Gingivectomy, Gingival Flap, Osseous Surgery,
Bone Grafts, Guided Tissue Regeneration
Full mouth radiographs,
Complete periodontal charting, and
Diagnosis.
Periodontal Scaling and Root Planing
Full mouth radiographs for patients under age 19.
Tissue Grafts
Diagnosis, and
Complete periodontal charting
** Fixed Bridges
Full arch radiographs
Partial and Complete Bone Impaction Removal and
Removal of Complete Impaction with Complications
Pretreatment periapical, and
Narrative (provide patient specific rationale
supporting the need for removal)
