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 Speed eClaimSM 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)
    		•
     
    Internal Bleaching
     
  • Pretreatment periapical
    		•
     
    Crown Repairs, Complicated Sutures, General Anesthesia/IV Sedation, Therapeutic Parenteral Drugs, Post-surgical Complications, Occlusal Guards
     
  • Narrative (describe patient's condition, repair, complication or drug used. For lab repairs, include a copy of the lab bill.)
    •  
     
    ** If endodontic treatment has been provided, a post-operative endodontic radiograph is also required showing all apices.



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