Dental BulletinPacificSource logo

Winter 2018

In this issue:

The PacificSource-Advantage Update: New Leadership, Same Commitment to Partnership >

PacificSource Dental Continues Upward Trend >

CDT 2018 Dental Code Changes >  

Crowns – Claim Requirements and Clinical Standards >

Expedite Your Preauthorizations with Documentation >

Questions? We’re Happy to Help >


The PacificSource-Advantage Update: 
New Leadership, Same Commitment to Partnership

PacificSource Health Plans and Advantage Dental entered into a partnership in July 2009, when PacificSource acquired Advantage’s 35,000 commercial plan members and made Advantage its exclusive dental network. Over the past seven years, the two organizations have formed a strong alliance, working together to improve access to quality dental care in the communities we serve.

Thanks and farewell to Dr. Mike Shirtcliff

As many of you know, R. Mike Shirtcliff, DMD, stepped down as President of Advantage Dental at the end of December 2017 to further pursue his life’s work of oral health for all by seeking elected office. 

Dr. Shirtcliff, along with a group of dentists from rural Oregon, founded Advantage Dental in 1994, and built the organization from the ground up. Over the years, they’ve remained steadfast to their goals of providing care and education to prevent dental disease, and these goals align well with the PacificSource mission and core values. 

“We at PacificSource sincerely thank Dr. Shirtcliff for his many years of dedicated service, vision, and passionate leadership,” says Dr. Jim Gimarelli. “We wish him all the best in his future endeavors.” 

Welcome Ellie Naderi

We’re also very pleased to welcome Ellie Naderi, who joined Advantage as the new CEO on January 8, 2018. Ms. Naderi has more than 22 years of both clinical and business operations experience in oral health practice settings. Most recently, she served as Senior Vice President Dental Hygiene Operations for DentalOne Partners, a leading industry innovator focused on supporting smart, technologically advanced practices. Prior to that, she held several leadership positions with Coast Dental, served as a dental hygiene educator and practiced as a registered dental hygienist serving diverse groups of patients. 

As with any leadership transition, there may be changes and adjustment, but both PacificSource and Advantage are strongly committed to continuing our partnership and building on our successes in the coming years. 


PacificSource Dental Continues Upward Trend

We’re pleased to report that PacificSource experienced an outstanding 2017 for our dental product with high numbers in sales and group retention, as well as positive claims and customer service measures. Here are a few highlights:  

  • Eight new large group dental clients with January 1, 2018 effective dates. These groups will bring in more than 10,500 new dental members, increasing our commercial dental membership by 15%.
  • Our retention rate of dental group clients was 82%. 
  • Over the last rolling 12 months, we have retained over 92% of our large group (i.e., groups over 50 employees) dental business.
  • Our dental call answer speed averaged just 26 seconds.
  • Our claims turnaround time averaged 9.5 days.  

In addition to these successes, for the second year, we sent emails and postcards to dental members who had not seen the dentist in the previous year. The message, encouraging them to take advantage of their preventive dental benefits, resulted in several hundred of these members making dental appointments over the summer for exams and cleanings. We intend to repeat this campaign annually.


CDT 2018 Dental Code Changes

The American Dental Association has published CDT 2018. This replaces CDT 2017 as the reference document for dental services beginning January 1, 2018, through December 31, 2018. Effective January 1, 2018, providers should begin using CDT 2018 codes on claims forms to report services provided to eligible members.

As a courtesy, CDT 2017 codes will continue to be accepted for three months in accordance with PacificSource policy but will not be processed after March 31, 2018.

Eighteen new codes have been added for 2018, sixteen codes were revised, and three codes deleted. Codes that will be covered with limitations are listed below:  

  • D5511 — repair broken complete denture base, mandibular
  • D5512 — repair broken complete denture base, maxillary
  • D5611 — repair resin partial denture base, mandibular
  • D5612 — repair resin partial denture base, maxillary
  • D5621 — repair cast partial framework, mandibular
  • D5622 — repair cast partial framework, maxillary
  • D8695 — removal of fixed orthodontic appliances for reasons other than completion of treatment
  • D9222 — deep sedation/general anesthesia – first 15 minutes
  • D9239 — intravenous moderate (conscious) sedation/anesthesia – first 15 minutes 

New implant codes (D6096, D6118 and D6119) will be covered for members with an implant benefit. Corticotomy (D7296 or D7297) will be covered for members with an orthodontic benefit.  


Crowns – Claim Requirements and Clinical Standards

Please be aware of PacificSource’s documentation requirements for crowns:

  • Pre-operative x-rays. If endodontic therapy has been performed, a periapical radiographic image clearly showing the apex of the completed treatment is required; otherwise, bitewing x-rays may be sufficient at the discretion of the reviewer. 
  • A narrative or photograph may provide additional information, especially for replacement of existing crowns. 
  • “Cracked tooth syndrome” requires adequate documentation of extent of fracture, location and how it was diagnosed. Tooth must be symptomatic. 

PacificSource uses national standardized utilization review guidelines when evaluating claims for crowns. In accordance with these guidelines, crowns are not indicated in the following circumstances: 

  • If a lesser means of restoration is acceptable. 
  • Solely for cosmetic or aesthetic reasons (peg teeth, diastema closure, discoloration). 
  • For alteration of vertical dimension.
  • For purposes of preventing future fracture, or to eliminate enamel craze lines. (Cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative; tooth must be symptomatic. See AADC guidelines below.) 
  • To treat nonpathologic wear or abrasion, or abfraction lesions in the absence of decay. 
  • Fracture of porcelain not involving the margin or a functional ridge. 

About Cracked Tooth Syndrome (CTS)

For CTS, the American Association of Dental Consultants (AADC) has issued the following position statement and conclusions:

Given the preponderance of current best evidence, it is the position of the AADC that conservative treatment be initially recommended for a tooth demonstrating symptoms consistent with “cracked tooth syndrome.” Furthermore, an asymptomatic tooth or a tooth with craze lines does not require endodontic services, crowns, or additional treatment. An asymptomatic tooth, with no history of pain cannot be defined as CTS.

AADC’s conclusions: Cracks and craze lines in teeth are common; molars are most commonly involved; and asymptomatic teeth do not need to be treated. 


Expedite Your Preauthorizations with Documentation

With the New Year and renewed dental benefits, we will have an increased amount of patient/member dental preauthorizations. When sending your preauthorization requests, please remember to send the supporting documentation for the procedures. Sending the correct information with ensure a quicker turnaround time for your patient’s preauthorization.

An example of supporting documents for anterior fillings, crowns, dentures, implants, and bridges would be chart notes with clinical findings and x-rays. For scaling and root planning or periodontal surgery, we require x-rays along with a perio chart and for D4910-Perio Maintenance. We will also need the member’s prior history of root planning or perio surgery dates along with a perio chart.  


Questions? We’re Happy to Help

Contact PacificSource Dental Customer Service for Questions Concerning:

  • Member benefits or eligibility
  • Status of a specific claim or EOP


Phone: Eugene: (541) 225-1981. All other areas: (866) 373-7053

Fax: (541) 225-3655

Contact Advantage Provider Relations for Questions Concerning:

  • Becoming a contracted provider
  • Provider contracts


Phone: (866) 268-9616


Fax: (866) 268-9318



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