Complex Care Pathways are designed for patients aged 16 and over with specific clinical needs.
Topics Covered
- Entry Criteria
- Submission & Operational Requirements
- Concurrent Claims & Exemptions
- Key Restrictions
- Appendix
There will be three types of Complex Care Pathways. The pathways will involve the submission of multiple claims while the pathway is underway, and the UDAs will be broken down and awarded in stages on submission of each claim.
The three care pathways are:
- Pathway 1
- Pathway 2
- Pathway 3
Entry Criteria
The three care pathways are Pathway 1, Pathway 2, and Pathway 3. Each Pathway has there own pathway criteria:
Pathway 1 (Code 9191): Patients with 5+ teeth with caries into dentine (6 submissions, £284 total).
Pathway 2 (Code 9192): Patients with 5+ teeth with caries into dentine and unstable periodontitis (12 submissions, £709 total).
Pathway 3 (Code 9193): Patients with a first diagnosis of Stage III or unstable Grade C periodontitis or higher (6 submissions, £248 total).
Refer to the Appendix for more details.
Pathway |
Description & Pathway Entry Criteria |
New Code |
Total Payment |
Number of submissions expected |
Payments for Each Submission |
|---|---|---|---|---|---|
| Pathway 1 | Patients aged 16 years and over, with five or more teeth with caries into dentine. |
9191 |
£284 |
6 |
£47.33 (5 months) £47.35 |
| Pathway 2 |
Patients aged 16 years and over, with five or more caries into dentine and unstable periodontitis as defined by the British Society of Periodontal Disease (BSP) classification of periodontal disease, evidenced by:
|
9192 |
£709 |
12 |
£59.08 (11 months) £59.12 |
| Pathway 3 |
Patients aged 16 and over, with a first diagnosis of Stage III or unstable Grade C disease or higher as defined by the British Society of Periodontal Disease (BSP) classification of periodontal disease, evidenced by:
|
9193 |
£248 |
6 |
£41.33 (5 months) £41.35 |
-
Depending on whether the pathway is suspended or not and when the completion claim is submitted, the total duration of a CCP shall not exceed the below:
Pathway 1: 9-12 months
Pathway 2: 15-18 months
Pathway 3: 9-12 months
Submission & Operational Requirements
- Sign-up (Submission 1): You must sign the patient up using the specific pathway.
-
Interim Declarations: You must actively submit monthly declarations confirming the patient is still receiving care. These cannot be automated; the clinician must initiate them.
- Interims must be submitted in sequence.
- It is recommended that each of these claims to be sent no earlier than the beginning of the subsequent month.
- If you miss an interim declaration, credits pause until the submission is received.
- Final Declarations
- Dates: All submissions must use the same Date of Acceptance as the sign-up. Only the final declaration requires a Date of Completion.
- Automatic Closure: Pathways are automatically marked as incomplete if they remain suspended for over 3 months or if the completion declaration is not received within the required timeframe (9 months for pathways 1 & 3; 15 months for pathway 2). No UDAs are awarded for automatically created incomplete pathways.
Concurrent Claims & Exemptions
- Allowed Concurrent Claims: Only Unscheduled Care (9190), Charge Exempt Denture Repair (9154), Denture Modifications (9384/9385), and Band 3 courses (excluding orthodontics) can overlap with a CCP.
- Patient Charges: Charges are generally Band 2 unless a Band 3 treatment is claimed, which triggers a Band 3 charge.
- Exemptions: Cannot be changed mid-pathway. Ensure the exemption status matches the sign-up submission for the duration of the pathway.
Key Restrictions
- A patient cannot be on more than one Complex Care Pathway at a time.
- Orthodontic courses and Band 1 or 2 treatments cannot be claimed concurrently.
- Any claim with overlapping dates outside of the approved list (Unscheduled Care, Denture Repair/Modifications, Band 3) will be rejected.
Appendix
Pathway Entry Criteria (Detailed)
Entry to pathway 1 requires that a patient is aged 16 years or over and has 5 or more teeth with caries into dentine on initial examination.
-
Entry to pathway 2 requires that a patient is aged 16 years or over and has 5 or more teeth with caries into dentine and unstable periodontal disease as defined by the British Society of Periodontology (BSP) classification evidenced by, one of the below:
- Periodontal probing depth of ≥5mm, or
- Periodontal probing depth of ≥4mm and
- Bleeding on probing, with a diagnosis of stage II Grade B periodontitis or above, where this diagnosis covers any of generalised unstable periodontal disease that is:
- Stage II Grade B,
- Stage II Grade C,
- Stage I Grade C (with the caveat that the probing depth may be <4mm, but bleeding on probing still required),
- Stage III Grade B,
- Stage III Grade C,
- Stage IV Grade B,
- Stage IV Grade C, And
- Generalised unstable disease (not localised) affecting > 30% of teeth on initial examination.
Entry to pathway 3 requires that a patient is aged 16 years or over with a first diagnosis of Stage III or unstable Grade C periodontal disease or above as defined by the British Society of Periodontology (BSP) classification evidenced by, one of the below:
- Periodontal probing depth of ≥5mm, or
- Periodontal depth of ≥4mm, and
- Bleeding on probing. And
- Generalised disease affecting > 30% of teeth on initial examination.
Where “Stage III” of the BSP classification covers:
- Stage III Grade A,
- Stage III Grade B,
- Stage III Grade C,
OR Where “Grade C or above” covers:
- Stage I Grade C (with the caveat that the probing depth may be <4mm, but bleeding on probing still required)
- Stage II Grade C,
- Stage IV Grade A,
- Stage IV Grade B,
- Stage IV Grade C)
Practices can use this guide to have an overview of the complex care pathways.