Administrative Manual

Our manual contains dental and medical policy and procedure information that can be used as a day-to-day reference by our providers and their staff.

Notification of content changes

Updates to manual sections are posted at the beginning of the month in which they occur and a notification is included in our newsletter, The Connection℠. Our newsletter is published in February, April, June, August, October and December. Sign up to receive our newsletters via email. Please review new content promptly to ensure you have the most current information.

Learn more about us, view our Code of Business Conduct policy or our confidentiality information and requirements.

Section

Revision date

Change

2/2023

Updated Responsibilities of Participation section

3/2021

Added link to member authorization to disclose information

12/2022

Added requirement to submit provider appeals via Availity Essentials effective March 1, 2023

4/2023

Updated treatment plans section

8/2023

  • Revised statement regarding certificates of medical necessity (CMN)
  • Simplified prosthetics statement

8/2019

  • Updated hyperlinks throughout
  • Updated name of anti-fraud department to Special Investigations Unit (SIU)

2/2022

Revised the Documentation Requirements section

8/2023

Added nuclear medicine imaging to the list of services included in our radiology program

10/2022

Added Medicare Star Ratings information

Medicare Advantage Compliance Requirements (PDF) Note: Our Medicare Advantage providers must comply with the requirements in this section, in accordance with the Medicare Advantage Provider Compliance Addendum.

4/2022

Updated regulatory references

8/2021

Updated with our current contact information

2/2023

Added information about fragmented/split professional billing

12/2020

Added this new section that includes the requirements for providers who care for members on our Individual and small group products

4/2022

Added information about provider education

4/2023

Updated treatment plans section