The SCE provides the ability to adjudicate limits that are configured on dental benefits. This capability is provided in the benefit limit accumulator processing module (SBL). The limits are identified on the benefit at the benefit level and the variation level.
From anatomical aspect, there will be one oral cavity, 2 arches (maxillary, mandibular), 4 quadrants (upper right, upper left, lower right, and lower left), 7 surfaces in total where in each tooth will have only 5 surfaces and 32 teeth in adults and 20 teeth in children. Based on these anatomical considerations, the benefit limits will be applied.
There are different types of dental benefit limits as specified below.
- Per Tooth Limit: Some of the dental services for any given tooth
number will be limited to only a given number of times for a given period
and this configuration can be given at PCS and SCE should consider the
limits configured and allow only the configured number of units for any
Example: Root canal treatment done on any specific tooth can be limited to only once in a calendar year.
- Per Surface Limit: For some dental benefits, the services for any
dental surfaces will be limited to only for certain number of times for
Example: Fillings done on any specific surface can be limited to 2 times within a period of 6 months.
- Per Quadrant Limit: Some of the dental services based on dental
quadrants can be limited to certain number of times for certain
Example: Quadrant specific cleanings will be covered only twice in a benefit year.
- Per Arch Limit: Some of the dental service based on dental arches can
be limited to certain number of times for certain period.
Example: Dental cleaning procedure for any of the dental arch (Maxillary or Mandibular) will be covered only once in a calendar year
- Per Benefit Limit: Some dental benefits can be limited only to
certain number of times for certain period.
Example: Benefit which covers dental scaling procedure will be allowed only once in a calendar year
The frequency of the benefit limits can be configured from the following options:
- Every calendar year
- Every benefit year
- A defined number of months.
If the calculation method for the benefit limits is not one of the above, then the SCE will set an appropriate event code due to a configuration or coding error.
Note:if there are any wrong dental configurations, event codes are reported acknowledging this.
For example, if the limit type is a tooth limit then the calculation method should be per tooth and if it is configured with any other calculation method like per unit, per condition etc. then invalid configuration event will be raised.Accumulator retrieval and processing
The SCE uses the limit information along with the benefit to retrieve accumulators or create new ones for adjudication. Multiple accumulators can be updated separately on the same claim for each specific surface, quadrant, arch, tooth, and benefit. In addition, if the benefit limits are defined to contribute across networks, then cross network accumulators are also defined and utilized.
Once each accumulator has be retrieved or created, the service units are compared to the remaining units on the accumulator. If the accumulator is exhausted, event code SBL-0005 (benefit limit exhausted) is assigned to the claim. If the service is limited, as there are units available on the accumulator, but not enough to satisfy the units available on the claim, the approved units is set to the remaining available, and an adjustment for the difference is created with reason code 119 (benefit maximum for this time period or occurrence has been reached) or 273 (coverage/program guidelines were exceeded).
Each limit SCE will create/update accumulators separately for each specific surface, quadrant, arch, tooth, and benefit. Claim would be adjudicated limiting the service to the maxed defined on the benefit/accumulator.
Once the dental limits are met then SCE will deny all the exceeded units and then respective pend/deny event code will be set.Benefit limit override
If the claim has previously processed against an authorization, and the authorization contains units that exceed the configured or available benefit limit, the claim will be processed against the authorization and the benefit limit will be updated in the accumulator to contain a revised maximum value. When this occurs, an action code of BENAU is applied to the claim.
Note: the application of this action code occurs both in the benefit limit processing and the authorization processing, depending upon the order of modules being executed.Benefit limit event codes
|SBL-0001||Invalid per tooth limit configuration||The benefit matched to the service line is configured with a tooth limit, but with a calculation method other than per tooth. The benefit limit cannot be correctly determined.|
|SBL-0002||Invalid surface limit configuration||The benefit matched to the service line is configured with a surface limit, but with a calculation method other than per surface. The benefit limit cannot be correctly determined.|
|SBL-0003||Invalid arch limit configuration||The benefit matched to the service line is configured with an arch limit, but with a calculation method other than per arch. The benefit limit cannot be correctly determined.|
|SBL-0004||Invalid quadrant limit configuration||The benefit matched to the service line is configured with a quadrant limit, but with a calculation method other than per quadrant. The benefit limit cannot be correctly determined.|
|SBL-0005||Unit limit exhausted||The unit limit for the accumulator has been met and no additional units for this service are allowed.|
|SBL-0006||Tooth number missing||The service code billed requires a tooth number to be indicated and no tooth number was billed.|
|SBL-0007||Accumulator span not supported||The date span for this accumulator defined in the benefit plan is not supported by the system.|
|SBL-0008||Surface code missing||The service code billed requires a tooth surface code and no tooth surface code was billed.|
|SBL-0009||Quadrant indicator missing||The service code billed requires a quadrant to be indicated and no quadrant was billed.|
|SBL-0010||Arch indicator missing||The service code billed requires an arch to be indicated and no arch was billed.|
|SBL-0011||Invalid lifetime maximum configuration||The benefit matched to the service line is configured with a lifetime maximum, but the limits configured period basis is not lifetime and the limits configured calculation method is not paid amount. The benefit limit cannot be correctly determined.|
|SBL-0012||Invalid benefit limit configuration||The benefit matched to the service line is configured with a benefit limit, but the configured calculation method is not per benefit. The benefit limit cannot be correctly determined.|
Note: benefit limits for medical claims are processed in the coverages and accumulators module (SCA).
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