Operational Guidelines - Ministry Of Health

Operational GuidelinesFor the Combined Dental Agreement (CDA)Issue 11: July 2020

Published First in January 2006Ministry of HealthPO Box 5013, Wellington, New ZealandISBN 0-478-24338-3 (Book)ISBN 0-487-24339-1 (Internet)This document is available on the Ministry of Health Website:http://www.moh.govt.nz2Combined Dental Agreement: Operation Guidelines for Oral Health Services for Adolescents andSpecial Dental Services for Children and AdolescentsVersion 9: July 2020

All District Health BoardsDocument Control SummaryAmendment to the Operational Guidelines for the Combined Dental Agreement (CDA) will benumbered consecutively and dated by the issuer.Please ensure that all amendments are inserted and complete the record below.VersionDate IssuedSections Re-issuedInitials0January 2006New DocumentMoH1July 200723July 200821 DHBs4March 2011New Document20 DHBs5June 2014New Document20 DHBs6July 2015New Document20 DHBs7July 2016New Document20 DHBs8July 2017Variation20 DHBs9July 2018Variation20 DHBs10July 2019New Document20 DHBs11July 2020Variation20 DHBs3Combined Dental Agreement: Operation Guidelines for Oral Health Services for Adolescents andSpecial Dental Services for Children and AdolescentsVersion 9: July 2020

Summary of Changes to Operational Guidelines effective from 1 July2020The Operational Guidelines have been amended to include the following changes:1. Section 6.1.2 Consultations – Special dental service (CON3)Paragraph changed to clearly express when CON3 may be claimed and when not to be used.2. Section 6.2.11 Pulp and root canal treatmentParagraph 3 regarding additional fees has been added.3. Section 6.3.12 Bite splintsSentence added to paragraph 2 on bite splints will only be considered for the permanentdentition.4. Section 4.2, 11.2, 11.3 and 11.4Change made to these sections to require “The name and DCNZ registration number of thetreating clinician (or the DCNZ Person ID for clinicians without a DCNZ registration number)."4Combined Dental Agreement: Operation Guidelines for Oral Health Services for Adolescents andSpecial Dental Services for Children and AdolescentsVersion 9: July 2020

ContentsDocument Control Summary . 3Summary of Changes to Operational Guidelines effective from 1 July 2019 . 41.Introduction . 82.General guidelines . 92.13.4.5.General definitions. 92.1.1Oral health services for children and adolescents . 92.1.2Fee for service . 92.1.3Standard (capitated) package of oral health services for adolescents . 92.1.4Additional oral health services for adolescents not requiring prior approval . 102.1.5Additional oral health services for adolescents requiring prior approval . 102.1.6Special dental services for children and adolescents . 102.1.7Special dental services for children and adolescents not requiring prior approval . 102.1.8Special dental services for children and adolescents requiring prior approval . 102.2Where prior approval is required . 102.3High caries treatment planning . 102.4Services not provided under this agreement. 122.5Queries . 122.6Providers required to provide treatment . 12Audit Guidelines . 133.1Audit . 133.2Investigation. 13Information Guidelines . 144.1Computer claiming . 144.2Agreement number. 144.3Assigning or ending your agreement . 144.4Identification of patients and providers . 144.5National Health Index (NHI) number . 15Payment Guidelines . 165.1Goods and Services Tax (GST) . 165.2Identification of payments . 165.3Seeking approval for additional oral health services for adolescents requiring priorapproval . 165Combined Dental Agreement: Operation Guidelines for Oral Health Services for Adolescents andSpecial Dental Services for Children and AdolescentsVersion 9: July 2020

6.5.4When can you expect payments? . 165.5General eligibility guidelines . 16Treatment Guidelines . 186.1Standard oral health services. 186.1.1Consultations – oral health services for adolescents (covered in capitated funding) . 186.1.2Consultations – special dental service . 196.1.3Posterior restorations – single surface (FIL1) . 196.1.4Preventive services - Fissure sealants, fluoride applications, oral health education . 196.2Additional oral health services not requiring prior approval. 206.2.1Posterior restorations two-and three surface restorations (FIL2 and FIL3) . 206.2.2Posterior complex restorations (FIL4). 206.2.3Anterior restorations – one-surface non- metallic (FIL5) . 206.2.4Anterior restorations – multiple-surface (MI, DI, MID) non- metallic (FIL6) . 206.2.5Routine extractions (non-surgical) . 206.2.6Emergency consultation outside normal hours . 216.2.7Emergency dressings. 216.2.8Preformed metal crowns . 216.2.9Recementation . 216.2.10Panoramic radiograph. 216.2.11Pulp and root canal treatment . 226.3Additional oral health services requiring prior approval . 236.3.1Minor oral surgery (including surgical extraction) . 236.3.2Bleaching . 236.3.3Splints (other than as a result of an accident) . 236.3.4Periodontal treatment . 236.3.5Prosthetic appliances – partial dentures . 246.3.6Prosthetic appliances – full dentures. 246.3.7Crowns . 246.3.8Anterior veneers . 256.3.9Inlays . 256.3.10Periapical radiograph . 266.3.11Apexification/root filling teeth with an open apex . 266.3.12Bite splints . 266Combined Dental Agreement: Operation Guidelines for Oral Health Services for Adolescents andSpecial Dental Services for Children and AdolescentsVersion 9: July 2020

7.0General. 277.1Pulp capping . 277.2Pins . 277.3Orthodontic treatment and extractions for orthodontic purposes . 277.4Implants . 277.5Bridges. 277.6Glass Ionomer cement or composite fillings in primary teeth . 277.7Sensibility test . 277.8ACC . 277.9Prescription of subsidised prescriptions . 278.0Children’s Act . 298.1.0Registered dental health professionals and dental assistants working under the CDAare children’s workers. 299.0Guideline for the Use of Fluoride and Minimal Intervention Strategies . 3210.0References. 3311.0Claiming guidelines . 3411.1The forms . 3411.1.1Enrolment form for adolescent oral health services . 3411.1.2Oral health services for adolescents and special dental services claim summary form .3411.1.3The oral health services for adolescents individual treatment report . 3411.1.4 Oral health services in high caries treatment planning (adolescents) treatmentreport/claim summary form . 3411.1.5Special dental services agreement individual treatment form . 3511.1.6Application for approval to provide treatment not covered by standard fee schedule3511.2Steps for making a claim – adolescents oral health services . 3511.3Steps for making a claim - high caries treatment planning . 3811.4Steps for making a claim - special dental services treatment. 3911.5Processing system . 4112.0Codes and Descriptions . 4213.0Conflicts of Interest . 447Combined Dental Agreement: Operation Guidelines for Oral Health Services for Adolescents andSpecial Dental Services for Children and AdolescentsVersion 9: July 2020

1. IntroductionThese guidelines have been developed to assist oral health providers in providing oral health servicesto adolescents and special dental services for children and adolescents.These guidelines cover a range of issues including definitions of treatments information and reporting requirements payment processes audit protocols.These guidelines should be read in conjunction with your CDA and any subsequent amendments orvariations. These guidelines may be updated from time to time in consultation with 20 District HealthBoards (DHBs) and the New Zealand Dental Association.Please retain these guidelines to assist your provision of oral health services to adolescents andchildren under the Agreement.For further assistance in interpreting these Guidelines at a regional level, please contact the ADO whoapproves treatment for your DHB.8Combined Dental Agreement: Operation Guidelines for Oral Health Services for Adolescents andSpecial Dental Services for Children and AdolescentsVersion 9: July 2020

2. General guidelines2.1General definitionsThe following is a list of general definitions relating to the provision of oral health services foradolescents and special dental services for children and adolescents. Dentists, dental therapists, oralhealth therapists and dental hygienists may contract to provide both oral health services foradolescents and special dental services for children and adolescents or either only oral health servicesfor adolescents or special dental services for children and adolescents.2.1.1 Oral health services for children and adolescentsA term describing oral health services for adolescents from Year 9 at school until the day before their 18th birthday and children, year 8 and under at school, or pre-schoolers under five years of age, who have beenreferred or officially released early from the Community Oral Health Service as not being able tobe treated by them due to medical or management reasons.2.1.2 Fee for serviceA method for funding services where a fee is paid for each item of treatment provided.2.1.3 Standard (capitated) package of oral health services for adolescentsA method of funding services where a price is paid per annum for a prescribed list of treatment (seesection E5.1 of the CDA) for each enrolled patient. The price covers a range of services from which aprovider can choose the combination that best meets individual patient’s needs. This includesdiagnostic services, operative and preventive treatment.The capitation model enables the provider to meet individual patient needs, noting these will varybetween patients. The capitated funding model allows for those patients that require preventive careand/or occasional restorative work to be offered a package of dental care appropriate to their needswhile ensuring providers are remunerated adequately. Through capitation funding a satisfactoryaverage level of remuneration is achieved from providing services to a group of patients with a mix oforal health needs.The CDA’s Oral Health Services for Adolescents (OHSA) provides a capitated package of services thatincludes an annual examination and where required: An annual examination and all other necessary consultations within the 12 month period(excluding emergency consultations outside of normal practice hours).Bite wing and periapical radiographsProphylaxis, including removal of supragingival calculusFissure sealantsSingle surface restorations (FIL1)Preventive treatment, including oral health education and topical fluoride applications.Any further necessary consultations throughout the year should be coded as a CON2. Whilst there isno fee payable it is important for data collection that this information is recorded.9Combined Dental Agreement: Operation Guidelines for Oral Health Services for Adolescents andSpecial Dental Services for Children and AdolescentsVersion 9: July 2020