SCPHCA Dental Provider Updates

Agenda

Introduction Latest News Web Portal Navigation Related Documents Claim Completion Reminders Prior Authorization Reminders Coordination of Benefits Questions

*Helpful Hints* are identified throughout the presentation

Introductions

DentaQuest

Tycie Sellers, Provider Relations Representative

Latest News

Express Lane Eligibility Initiative Adding approximately 70,000 new beneficiaries Children are already eligible, but were not enrolled Automatic enrollment by SCDHHS Dental Providers may encounter new patients Utilization by new beneficiaries being monitored

Foster Care Initiative SCDHHS and SCDSS collaborating to ensure care

coordination for foster children No impact to provision of dental services

Reminder of Adult Coverage Limitations

Treating Adults dental services may be reimbursable when performed in preparation for or during

the course of treatment of one of the established medical conditions outlined in the Dental ORM:

Organ transplants Chemotherapy Radiation of head and/or neck for cancer treatments Total joint replacement Heart valve replacement Treatment of trauma related injuries in a hospital/outpatient setting

Effective January 1, 2012, medical services (covered oral surgical procedures) may be billed by oral surgeons

Covered CPT procedures only Rendered to members age 21 and older in emergency situations Include required documentation and indication of emergency on claim submission:

CMS 1500 Form: check field 24C Web submission: including the word “emergency” in the remarks field

Utilization will be monitored by DentaQuest and SCDHHS Program Integrity

Insure Kids Now OutreachFederal initiative connecting kids

to coverage Part of the Children’s Health Insurance

Program (CHIP) Renewal Act of 2009 Mandates state Medicaid agencies to

supply quarterly provider directories that reflect up-to-date data on office locations and more detailed information on office hours, languages spoken, and special capabilities

www.insurekidsnow.gov If your office has not supplied this

form back to DentaQuest, please do so as soon as possible!

Additional copies available on Provider Web Portal and from Customer Service

DentaQuest Provider Web Portal

https://govservices.dentaquest.com/

Enter your Username and Password to access the Dentist Home Page

1. Portal Menus2. Welcome-This section contains

the DentaQuest welcome message.

3. Plan Messages-Contains any plan messages from DentaQuest.

4. Health News-Contains information and news articles of interest.

5. My HealthTools/Resources-contains links to various health resources.

6. Contact-Contains DentaQuest’s contact information.

7. Message Center-Contains messages sent to you from DentaQuest. (appears if you have messages in your Inbox.)

8. FAQ-This link opens to view frequently asked questions.

9. Event Calendar-This link opens the Event Calendar.

10. Related Documents-This link opens the Document List page.

Dentist Home Page

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*Helpful Hint*

“Related Documents”

contains helpful

resources such as: Current ORM Fee Schedules SCDHHS Provider

Bulletins Appeal Form

Dental Office Reference ManualThe most current version is always available through the provider web portal.

Important contact information Review of SCDHHS policy Explanation of procedures Claim filing options Prior Authorization

Requirements and Processes Benefits and Limitations Recommended clinical criteria

Dental Office Reference Manual

To review covered benefits, refer to

Exhibit A for Children Exhibit B for Adults Exhibit C for coverage within the Mental Retardation and Related

Disabilities (MR/RD) Waiver Program.

Benefits are listed by Code Brief Description of the Benefit Age Limitations Teeth Covered Review Requirements Benefit Limitations Documentation Requirements

January 1, 2012 Release of the ORMUpdated Format to Benefit Tables

OLD FORMAT

Code

Description

Age Limitation

Teeth Covered

Review Required

Benefit Limitations

Documentation Required

D2940 Sedative Filling 0-20 Teeth 1 through 32, A through T

No Not allowed with D2000 or D3000 series codes. Limit of one per 36 months per tooth.

NEW FORMAT

Code

Description Age

Limitation

Teeth Covered Review

Required

Benefit Limitations

Documentation Required

D2940 Protective Restoration 0-20 Teeth 1-32, A-T No One of (D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394, D2930, D2931, D2932, D2934, D2950, D2951, D2954, D3220, D3310, D3320, D3330) per 1 Day(s) Per Patient. One of (D2940) Per 36 month(s) Per Patient. Not allowed with D2000 or D3000 series codes on the same date of service.

CDT Fee Schedule

ProcPayment Rate prior

to 04/08/2011

Payment Rate 3% reduction effective 04/08/2011

Payment Rate 3% reduction effective 07/11/2011

D0120 $23.40 $22.70 $22.00

D0140 $38.34 $37.19 $36.04

D0145 $23.40 $22.70 $22.00

D0150 $40.94 $39.71 $38.48

D0210 $53.29 $51.69 $50.09

D0220 $13.65 $13.24 $12.83

D0230 $11.05 $10.72 $10.39

D0240 $20.15 $19.55 $18.94

D0270 $13.00 $12.61 $12.22

D0272 $20.15 $19.55 $18.94

D0330 $53.29 $51.69 $50.09

D1110 $43.54 $42.23 $40.93

CPT Fee Schedule

ProcPayment Rate prior to

04/08/2011

Payment Rate 3% reduction effective 04/08/2011

Payment Rate 3% reduction effective 07/11/2011

13132 $415.05 $402.60 $390.15

20670 $275.97 $267.69 $259.41

20680 $423.15 $410.46 $397.76

20900 $297.43 $288.51 $279.58

20902 $265.42 $257.46 $249.49

21025 $636.61 $617.51 $598.41

21026 $420.13 $407.53 $394.92

21029 $537.29 $521.17 $505.05

21030 $351.66 $341.11 $330.56

21031 $269.34 $261.26 $253.18

21032 $272.91 $264.72 $256.54

21034 $966.92 $937.91 $908.90

Appeal Form

DentaQuest Provider Appeal Form

DentaQuest Attn: Complaints & Grievances 12121 N. Corporate Pkwy. Mequon, WI 53092

Member Name: _________________________________________________ Member Identification Number: ___________________________________ Date of Service: _________________________________________________ Date EOB was received: __________________________________________ Authorization Number: __________________________________________ Date Authorization was received: __________________________________ ------------------------------------------------------------------------------------------------ Provider Name: _________________________________________________ Location Number: _______________________________________________ Office Contact: __________________________________________________ Office Phone Number: ____________________________________________ ------------------------------------------------------------------------------------------------ Reason for Appeal: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Outcome office is requesting: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Patient Menu Member Eligibility Search

Performing a Member Eligibility Search

Click Member Eligibility Search in the Patient menu to display the Member Eligibility Search page.

• Select the provider from the Select a Location and Provider drop-down list.

• Type in the Service Date.

• Type in the DOB (date of birth) in mm/dd/yyyy format or select it from the pop-up calendar in the DOB field. *This is a required field.

• You must enter a DOB and Member Number -OR- a DOB and Last Name and partial First Name.

• To add additional rows click Add Member. (Able to search up to 30 members at one time)

• To delete a member from the search, click the Delete link at the end of the row.

• Click Search-the Member Eligibility List page will appear.

Member Eligibility List

•Active (Eligible): there is a match between the member's active coverage and the dentist's active networks on the date of service.•Ineligible (Not Eligible): the member is not active on the date of service. •Not Found (Member Not Found): a matching member could not be identified.•Click the Member Name link to display the Member Detail page•Click Search Again to redisplay the Member Eligibility Search page and repeat the search process•Click Download File to download the search results•Click on Printer Friendly Format to print the results

Member Detail Page

• To view benefit maximums (if applicable), click on View Benefit Maximums, the Benefit Maximum detail screen will appear.

• To view a list summary of claims for the specific member, click View Claims; the Claim Status List page appears.

• To view the member’s service history (available if they are eligible), click View Service History; the Member Service History page appears.

• To search for a dentist, click View Provider Directory; the Find a Dentist page appears pre-populated with information for the dentist you selected in the eligibility check.

• The Eligibility Information section lists the current Plan name.• The Other Coverage section lists cross-coverage information (COB) for the member.

Broken Appointment

Click on Broken Appointment in the Patient menu to add a Broken Appointment Enter Basic Information, Member Information and Appointment Details Click on Submit To enter another Broken Appointment click on Add a New Broken Appointment

Dental Claim Entry

Key

1. Basic Information-Service Date, Group NPI, Service Office, Treating Dentist and POS (Place of Service)

2. Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency, COB,EPSDT, Notes

3. Member Eligibility-DOB, Member ID, Last Name, First Name

4. Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt

5. File Attachments- click Add File to upload an attachment

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Dental Pre-Auth Entry

Key

1. Basic Information-Group NPI, Service Office, Treating Dentist and POS (Place of Service)

2. Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency, EPSDT, Notes

3. Member Eligibility-DOB, Member ID, Last Name, First Name

4. Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt

5. File Attachments- click Add File to upload an attachment

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Claim/Pre-Authorization Status Search

Search Criteria Key:

1. Member Last Name

2. Member First Name

3. Member Number

4. Member DOB

5. Servicing Dentist

6.Claim/Pre-authorization Number

7. Type: Dental Claim or Pre- Authorization

8. Status Category: Successfully Entered, Accepted, In Process, Adjudicated, Finalized

9. Date From/To: Enter the Date of Service

10. Claim Received Date From/To: Enter the Claim or Pre-auth Received Date.

This page allows you to conduct a claim or pre-authorization search. **At least one search criteria must be entered to perform a search**

Claim/Pre-Authorization Status ListThis page appears with any claims or pre-authorizations that met your criteria search

• To download the list, click Download File• To view details on a claim/pre-authorization, click the Claim/Pre-Authorization Number link• To view the member’s details for a claim, click the Member Name link• To view the Dentist Directory Detail page, click the Dentist link for a claim• To perform a new search, click Search Again • To perform a remittance advice search, click RA Search

Claim Status Categories and Descriptions

Description DefinitionSuccessfully Entered The claim/encounter has been successfully entered.

Accepted The claim/encounter has been accepted into the claim adjudication system.

In Process The claim/encounter is being processed in the claim adjudication system.

Adjudicated The claim/encounter has been completed. Waiting to process payment.

Finalized The claim/encounter has completed processing and payment (or approval for a pre-authorization). No more action will be taken.

The following table lists and describes the claim status categories for your claims and pre-authorizations in the Portal.

Adding Billed Amount Lists

1. On the Administration menu click on Billed Amount List.

2. Click the Add Billed Amount List link.

3. In the Billed Amount List Name enter the name you want the list to have.

4. In the Code field enter the first code you are entering to the list.

5. In the Fee Amount field enter the fee for the procedure code.

6. Click the plus arrow to add a new code. Repeat step 6 for each procedure code you are adding to the list.

7. Once you have added all the procedure codes and fee amounts, click Submit.

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Adding Billed Amount Lists cont.

8. On the Billed Amount Detail page that appears, click the Add Billed Amount Association link.

9. In the Service Office field on the Add Billed Amount List Association page select the service office you want to associate this list with from the drop-down list.

10. Click the Add button to add the association.

The billed amount list and association is now active for this service office.

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Tools Menu

Click the Tools menu to display the sub-menu items:

• User Profile- Use this sub-menu to view your user information and change your name, password, and email address.

• Inbox- use this sub-menu to view and manage any messages sent to you

• Contact DentaQuest- use this sub-menu to send secure messages

• Find a Dentist - Use this menu item to search for a specific type of dentist, view detailed provider information, and get directions to a dentist’s office.

Send Secure Messages1. Message Type-select from the

drop-down list: Location Information Change, Provider NPI Info, Provider Authorization, Provider Claims, Remittance Documents

2. Attachment- To add an attachment click on Upload. You can have only one attachment per message

3. Claim/Pre-Authorization Number -Click on Search to search for a claim or pre-authorization

4. Dentist Name- Click on Search to search for a Dentist Name

5. Description-Type your question, comment or suggestion in the text box.

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More Helpful Hints

*Helpful Hints*on Claim Submission

To ensure your dental claims are accepted please be sure to:

Include the treating dentist signature in box #53. Acceptable signatures include: “Signature on file”, electronic name and typed names.

Indicate in box #4 if the member has other insurance.

Check the appropriate Place of Service in box #38.

Remember to submit documentation along with the claim even when the services have been prior authorized

If you are supplying a voided claim, enter “void” or “adjustment” in the remark field box #35 and include a SCDHHS Form 130 with your submission.

*Helpful Hints*on Claim Submission

CDT claims must be submitted on a 2006 or newer ADA claim form (found at www.ada.org).

CPT claims must be supplied on a CMS 1500 claim form.

Mailed claims or authorization requests should be submitted to

P.O. Box 2136

Columbia, SC 29202-2136

Resubmit denied claims or service lines once. Multiple resubmissions will result in unnecessary duplicates.

*Helpful Hints*Submitting Authorization Requests

Indicated Predetermination/Preauthorization on an approved claim format. ADA Format: check Predetermination Box CMS 1500 Format: leave Date of Service blank Do NOT submit D9500

Methods of submitting Auth Requests: Electronically through your clearinghouse or the DQ web portal Paper Emergency submissions are accepted through the DQ emergency

authorization fax line or email address See your Dental ORM for detailed instructions

*Helpful Hints*on Providing Documentation: Narratives of Medical Necessity should be provided in the “Notes”

or “Remarks” field or included as an attachment. Include enough information to reflect the patient’s health situation

and why the elected services are medically necessary Be sure that the information is legible Patient chart notes can be helpful supplements to support medical

necessity

X-rays should be mounted and of diagnostic quality. Consider scanning and supplying X-rays as attachments.

Electronic submission is also available through National Electronic Attachment (NEA).

Keep your originals on file If you’d like your X-rays returned, so indicate by including a self-

addressed stamped envelope (SASE).

*Helpful Hints*Coordination of Benefits Indicate on the claim form if the member has other insurance

Attach a copy of the primary’s EOB whenever possible – especially if the primary policy has termed If you use NEA to do so, denote “COB information included” in the Remarks

field along with the attachment number If you upload the primary EOB through the web portal, be sure to check the

COB box

If the patient only has medical primary insurance, there is no need to file for COB with a dental claim

Medicaid beneficiaries cannot be charged deductibles or copayments under any active primary insurance policy

THANK YOU for your time and attention today!

QUESTIONS?

Provider Web Portal (PWP)www.dentaquest.com

Provider Customer Service and IVR888.307.6553

Beneficiary Customer Service and IVR888.307.6552