a new day for oral health in virginia tooth talk december 12, 2007
TRANSCRIPT
A New Day For Oral Health In Virginia
Tooth Talk
December 12, 2007
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Smiles For Children ProgramAn Overview
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Who’s Eligible and How to Apply?
To participate in Smiles For Children (SFC), recipients must first be eligible for Medicaid, FAMIS or FAMIS Plus.
Once eligible, recipients are automatically enrolled in the SFC program and receive a Member Handbook.
Recipients do not receive a SFC ID card. Recipients may use: Commonwealth of Virginia (blue and white) plastic identification MCO identification card
For questions regarding Medicaid eligibility, recipients should: Visit their local Department of Social Services
http://www.dss.virginia.gov/
For questions regarding FAMIS or FAMIS Plus eligibility, recipients should: Go online and visit: www.famis.org; or Call 1-866-87FAMIS (1-866-873-2647)
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Enrollee Eligibility
Doral uses the 12-digit Medicaid ID number as the enrollee ID Number.
Eligibility may be confirmed using: Doral website By calling 1-888-912-3456 DMAS MediCall voice response system at 1-800-884-9730 or 1-800-
772-9996.
If DMAS Medicall voice response system is used, providers are cautioned to listen to the entire messagelisten to the entire message. Members may be in a waiver program, such as the Family Planning Waiver, and may not be eligible for dental benefits.
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Interactive Phone System
AVAILABLE 24 HOURS A DAY!AVAILABLE 24 HOURS A DAY!
By dialing 1-888-912-3456 and choosing option 1 providers can access: Patient Eligibility Limited Claims History Fax Back Confirmation of eIVR call Spanish Call Handling
Patients eligibility can be verified on the eIVR along with limited claim history (codes: D0120, D0150, D0210, D0272, D0274, D0330, D1110, D1120, D1201, D1203, D1204, D1205, D1351, D5110, D5120, D5130 and D5140)
Confirmation fax of the eIVR available to providers who use the system
Option to choose Spanish or English
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Enrollee Eligibility – FAMIS MOMS
FAMIS MOMS receive comprehensive health care benefits during pregnancy and for two months following the end of pregnancy-this includes SFC dental benefits if under twenty one years of age. Detailed information is available at www.famis.org.
Providers are encouraged to contact Doral to verify eligibility prior to rendering services.
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Benefits For Enrollees Under Age 21
SFC provides comprehensive dental benefits for enrollees under the age of 21:– Diagnostic– Preventive– Restorative– Endodontics– Periodontics– Prosthodontics Removable– Prosthodontics Fixed– Oral Surgery– Orthodontics– Adjunctive General
A full explanation of benefits can be found in the Office Reference Manual, Exhibit A.
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Benefits For Enrollees Age 21 and Older
Coverage for adults, age 21 or older, is limited to medically necessary oral surgery and associated diagnostic services.
Diagnostic services include the oral examination and selected radiographs needed to assess the oral health, diagnose oral pathology, and develop an adequate treatment plan.
Extractions for adults must be medically necessary and be complicating the patient’s general health as documented by the dentist or medical provider: Severe periodontal infection which
causes acute pain, loss of appetite or weight due to pain or infection
Exacerbates a medical condition/medical management such as diabetes, heart valve condition
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Benefits For Enrollees Age 21 and Older
Services for adults require Prepayment Prepayment ReviewReview: Services requiring prepayment review,
require that proper documentation be submitted with the claim following treatment in order for the claim to be considered for reimbursement.
For all services that require Prepayment Review, Providers have the option of requesting prior authorization: Services requiring prior authorization/pre-
determination require that documentation regarding the medical necessity of the proposed treatment be submitted and authorization from Doral be obtained before the services are rendered.
A full explanation of benefits can be found in the Office Reference Manual, Exhibit B.
Oral surgery procedures not listed in Exhibit B may be covered under the member’s medical benefits through the Medicaid, FAMIS, or FAMIS Plus fee-for-service or managed care organization (MCO) program.
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Office Reference Manual
Policies and procedures Instructions for claims filing Benefits and limitations Instructions regarding services that require prior
authorization Orthodontia criteria Outreach services American Academy of Pediatric Dentistry (AAPD)
dental care guidelines Important phone numbers and addresses
The Office Reference Manual (ORM) is available on line:
Go to www.doralusa.com. Click on “Providers.” After logging in, “View Documents”
or
Download a copy from the DMAS website at http://www.dmas.virginia.gov
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Provider Web Portal (PWP)
Meets accessibility standards put forth by the ADA (Americans with Disabilities).
Users can use any browser – no longer limited to “Internet Explorer.”
New improved look for ease of use. Easy to read menu. Email form for streamlined
communication. Payment release dates so Providers
can easily track payment dates. Location information displayed for the
office staff to check accuracy and update the information via a contact form.
Claims and authorization entry still available with accurate reporting and tracking information.
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Enrollee Outreach Initiatives
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Broken Appointments
Broken appointments: A major concern for DMAS, VDA, ODDS, and Doral Recognized as expensive for dentists Lead to dentists unwillingness to participate in the
program
In December 2005, Doral implemented the Broken Appointment Tracking Initiative in order to collect data to better track, trend, and understand the issue
Doral uses the information to: Educate families regarding the importance of
appointments and compliance with treatment plans
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Broken Appointment Initiative
Broken Appointment Tracking Log Outcomes Over 10,000 broken appointments from SFC
participating dentists have been received since Fall 2006.
Enhancements to the Broken Appointment Tracking Form
Missed appointment - a missed appointment where the member or member representative did not call to cancel
Late Notice Cancellation (LNC) - a missed appointment with a cancellation less than 24 hours prior to the appointment time
Reason codes - 1) forgot about appointment., 2) conflict with schedule, 3) transportation 4) illness, 5) other.
Next Steps:
Broken Appointment Best Practices Questionnaire
Broken Appointment Focused Survey SFC Broken Appointment Pilot Program
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SFC Transportation Complaint Form
Analyses of data related to broken appointments indicate problems with transportation as one reason for broken appointments.
Providers are encouraged to report problems with transportation to DMAS. The SFC Transportation Complaint Form can now be used to report problems.
Smiles For Children Transportation Complaint Form (* Required fields)
*Today’s Date ___/___/___ Date of Problem ___________ Appointment Time: _______________
*Name of Dental Office: _____________________ *Telephone Number ________________
*Form Completed by _________________*Title ___________ *Fax Number _________________
Dental Office Street Address: _________________________________City ______________________
Patient (Recipient) Name ________________________ Medicaid ID Number: ________________
Name of Transportation Provider if known: _________________________________________
*Nature of Complaint: Please check all that apply
Medicaid Recipient NO-SHOW for DENTAL Appointment
If Transportation Issue Known by Dental Office please check all that apply below:
Transportation Provider NO-SHOW (i.e., did not arrive at all) Transportation Provider was LATE or EARLY Scheduled Arrival Time _________ Actual Arrival Time _________ Patient did not schedule transportation in time therefore missed appointment Wrong type of vehicle sent for trip (e.g. needed wheel chair van, needed stretcher, etc …) Told by LogistiCare at Time_______ Date _______that “No Provider Available” to do the trip Recipient rode too long on vehicle Time picked up _______ Arrived _______ Driver did not follow special instructions given for pick up, drop off or return trip Patient or Family not notified of change in provider, scheduled pick up or return time Incident/Accident (e.g., vehicle accident, incident on vehicle, etc.) Injuries? Yes___ NO ___ Other Issues with LogistiCare (please explain below) Ongoing or unresolved issue(s) that have been reported but are still occurring. Specifics of Incident ____________________________________________________________
First, FAX this form to the QA at your LogistiCare Regional Office. Use the number below:
Region l (Norton) 276-679-1666 ________ Region 2 (Bedford) 540-586-7838 ________ Region 3 (Richmond) 804-236-1586 ________ Region 4 (Norfolk) 866-872-3843 ________ Region 5/6 (C’ville) 434-971-6509 ________ Region 7 (Herndon) 703-707-6513 ________
Second, FAX this form to DMAS at 804-371-6035 in care of Bob Knox, Transportation Mgr or the DMAS
Contract monitor for your region: Bill Zieser (Reg. 1, 3 and 7) or Eileen Jackson (Reg. 2, 4 and 5/6).
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Interpreter Services- Pending Implementation
Title XIX of the Social Security Act requires Medicaid providers to provide non-discriminatory services to its clients including those with limited English proficiency.
In order to help providers with this requirement, DMAS has implemented a provision for reimbursement of interpreter services under the SFC program when there is a need and it relates to the treatment.
In order for the SFC dentist to be reimbursed for interpreter services performed at the dental office, the provider must submit documentation (invoice) of the services provided by and paid to a professional interpreter. The following elements must included in the documentation: Date(s) of Service Patient name and ID number Copy of the invoice showing the name, address and telephone number of the professional interpreter service,
the type and length of service, and the amount paid Mail the SFC Professional Interpreter Service Invoice Form along with the above documentation
to:Doral Dental
ATTN: Lori Howley12121 N. Corporate Parkway
Mequon, WI 53092 An interpreter services resource listing will be located on the DMAS website,
http://www.dmas.virginia.gov. A copy of the resource listing will also be available upon request.
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How to Locate a Provider
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Provider Directory
Contents: Provider name Practice name Office address(es) Telephone number(s) Provider specialty Panel status Office hours Languages spoken Any other panel limitations
Directory may be downloaded from the DMAS website at:
http://www.dmas.virginia.govhttp://www.dmas.virginia.govor or
from the Doral website at:from the Doral website at:http://www.doralusa.com
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Open Microsoft Internet Explorer and access www.doralusa.com.
Click on the “Find A Provider” button to continue.
Doral Dental USA Website
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Find A Provider
You must provide at least a zip code to perform a search.
Select VA-Smiles For Children from the drop down menu.
Click “Find Providers”
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Find A Provider Search Results
Search options allow you to narrow a search by: Provider Specialty Languages Spoken Mileage Radius Hospital
Affiliation
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Contact Information
Doral Smiles For Children Staff:
Cheryl Harris:
Project Director
Direct Line: (804) 217-8344
Fax: (804) 217-8348
Email: [email protected]
Anna Perez: Provider Relations Representative Direct Line: (804) 217-8392Fax: (804) 217-8349
Email: [email protected]
Kristen Gilliam:Outreach CoordinatorDirect Line: (804) 935-8589
Fax: (804) 217-8350
Email: [email protected]
DMAS Smiles For Children Staff: Sandra Brown, MSW:
Dental Program Manager Direct Line: (804) 786-1567Fax: (804) 786-5799Email: [email protected]
Dr. Marjorie Chema, DDS: Dental ConsultantDirect Line: (804) 786-6635Fax: (804) 786-5799Email: [email protected]
Lisa Bilik: Dental Contract Monitor Direct Line: (804) 786-7956Fax: (804) 786-5799Email: [email protected]
Thank You!Thank You!