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Spring 2012 Spring 2012 PROVIDER TRAININGPROVIDER TRAINING
April/May 2012
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WELCOMEWELCOME&&
INTRODUCTIONSINTRODUCTIONS
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Training Objectives
Credentialing and Recredentialing – required documentation, process, expectations
Authorization Submissions Top Claim Denial codes and
how to avoid these issues IVR self service functions –
how to access answers to eligibility and claims faster
Claims/authorizations using the Portal with attachments features
Sealant Program Direct Deposit
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CREDENTIALING AND CREDENTIALING AND RECREDENTIAING RECREDENTIAING
PROCEDURESPROCEDURES
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All new providers enrolling into Medicaid/Smiles For Children program are required to complete several documents in order for the application to begin the process of credentialing
The documents include the Smiles For Children Application, Participation Agreement, DentaQuest Contract, w-9, Copy of Dental License and Copy of Liability Policy
Read the application and complete all required fields. Those applications received with missing information or improperly
filled out the provider will get three opportunities to send the correct information.
Providers needing to make changes to his/her panel are required to submit the request on the Provider change form and letter of request (including a w-9) i.e. change of tax id, name change
All providers adding a brand new location are required to submit a provider change form w-9 and contract for the new location
The entire application and all required documents are available on the Provider Web Portal under Related Documents and can be downloaded including Provider change form
CREDENTIALING DOCMENTATION
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RECREDENTIALING POLICIES AND PROCEDURES
Recredentialing occurs every three years for Smiles For Children providers
A letter along with a Pre-Populated Recredentialing Application will be mailed to providers requiring recredentialing.
The Recredentialing applications must be completed and mailed back at least four weeks prior to term date of the application
If the recredentialing application is not completed on time, the provider will be terminated and will have to reapply as a new provider
Not completing the recredentialing application will result in claims not paying for Non-Par status
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TOP DENIALS WITH AUTHORIZATIONS AND CLAIMS
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AUTHORIZATION DENIALS AND RESOLUTIONS
UM receiving OR authorization claim requests with D9500•This is not the correct code to be submitted for OR
authorization. D9999 should be submitted by the provider for OR cases. The authorization request should include the explanation for need of medical necessity and clinical criteria to treat in the OR. A blanket statement is not acceptable.
•Must include tentative Date of Service and Place of Service
Submission received for OR cases not a medical reason to allow services in an hospital setting
•Must submit request with OR Criteria. See Section 15.00 of the ORM
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UM receiving Prior Authorization requests with inadequate diagnostic quality x-rays
• X-rays submitted with non-diagnostic quality x-rays will be denied
•Must submit prior authorization requests with diagnostic quality x-rays and narrative explanation of the need of medical necessity when appropriate
•When necessary submit photos to support the medical need (especially if this can not be determined solely from the x-ray)
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Authorization release requests are being received without an ADA claim form or a determination letter
• Must submit on an ADA claim form note in box 35 request to release auth and include authorization number. Due to our automated system the request must be on the ADA claim form.
• It is acceptable to submit the original authorization claim noting in box 35 the auth # and request to release authorization.
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Submissions for EPSDT are not being checked on box 1 of the ADA claim form
• Be sure and check EPSDT in box 1 of the ADA claim form • EPSDT requires review that EPSDT be indicated on the prior authorization request•Include need of medical necessity•Must include the actual treatment ADA code
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CLAIM DENIALS AND WAYS TO AVOID
Claims not being submitted with periapical x-ray• Codes that require periapical x-rays for payment must
be of diagnostic quality (documentation required for pre-payment review)
Claims are being submitted with no panorex or Full mouth series of x-rays
• Codes that require panorex or FMX x-rays for payment must be of diagnostic quality (documentation required for pre-payment review)
Receiving numerous claims as duplicated previously paid• Prior to resubmitting the claim review the status in the
Provider Web Portal
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Claims denying for narrative describing treatment and/or narrative regarding medical necessity
• Codes that require narrative of medical necessity for payment must be submitted (documentation required for pre-payment review)
Receiving claims with non-diagnostic or poor quality x-rays. The Dental Director can not make a determination with poor quality or non-diagnostic x-rays.
• Must submit with diagnostic quality x-rays to be reviewed for payment
X-rays are non supportive for code submitted• Submit code that reflects the code appropriately. Include
narrative supporting the code for more complex treatment Orthodontic claims denying for member terminated
• Claim must be submitted with last date member was eligible for services with D8999 including remaining balance. In remarks field include banding date and member in active treatment and authorization number.
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Orthodontic Quarterly (8670) submission not being sent with an actual date of service
• Providers must submit claims for 3 3 quarterly payments (D8670) and the claims must be submitted with an actual date of service at least 91 days apart from the last actual date of service.
Information sent shows no significant signs of infection or any other reason for tooth removal
• Submit appropriate information to show your findings (i.e. x-rays, photos, treatment notes)
Claims/x-rays and narrative not showing the necessary evidence of bone loss to support periodontal scaling and root planing
• Submit with perio charting, treatment notes or photos if necessary to support the codes submitted
Claims information for Nitrous Oxide are not indicating medically necessary
• Must submit with adequate need for using Nitrous Oxide Claim received notes member covered by another carrier but the EOB
not attached to claim• Resubmit claim with copy of the primary carrier’s EOB for
payment consideration
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CHANGES TO OFFICE REFERENCE MANUAL
EFFECTIVE MAY 15, 2012 Revised EXHIBIT A, D0210 – INTRAORAL-COMPLETE
SERIES (including bitewings): One of (D0210, D0330) per 60 Month (s) Per Provider and Location for children age six and older. Reimbursement per 36 months is no longer permissible.
Revised EXHIBIT A AND EXHIBIT B, D0330 - PANORAMIC FILM: One of (D0330, D0210) per 60 month (s) Per Provider and Location for members age six and older. Reimbursement per 36 months is no longer permissible.
If a member requires a panoramic film or intraoral complete series, including bitewings more frequently than once every 60 months, the claim must be supported with a narrative of medical necessity.
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IVR SELF SERVICE FUNCTIONS
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Ability to verify benefits and eligibility and obtain a procedure history
Ability to have information faxed back to youOnce member information (such as membership number
or date of birth) is entered, you will be able to jump between menus without re-entering that information
Caller dials Provider Services incoming phone number (888-912-3456)
Caller is prompted for English vs SpanishCaller enters NPICaller enters last 4 digits of TINIVR validates caller:
• If provider is found – continues to enter member information
• If provider is not found – continues to limited options
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Caller enters member information• Member ID (12 digit number only)• DOB• (First 4 characters of last name if the ID is alpha numeric)
IVR validates member information:• If member is found – continues to main menu• If member is not found – prompted to re-enter information
Main Menu (when both provider and member are found in system)• Eligibility • Benefit Sub Menu
• Benefit Summary• Benefit Detail• Procedure History
• Claims• Authorizations• Web Support• All other inquiries
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“Limited Menu” (for providers that are not in system)• Eligibility• Benefit Summary• Benefit Detail• All other inquiries
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SEALANT PROGRAM
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WHAT IS PREVENTISTRY?
DentaQuest’s Preventistry approach thoughtfully integrates benefits, programs and policies to
promote prevention-focused oral healthcare in order to achieve our vision of a world free of dental
disease.
Our Preventistry benefit program empowers dentists and engages members to take a more active role in improving oral health by providing coverage
and practical information about important preventive services.
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Dental caries is the most common chronic childhood disease, five times more common than asthma and almost 100%
preventable
Dental caries (decay) is a bacterial infection that can spread from tooth to tooth
Decay most often occurs (about 90%) in the deep grooves on the biting surfaces of molars
Preventing decay not only improves oral health but also reduces the cost of care
WHY FOCUS ON PREVENTIVE CARE?
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HOW CAN CARIES BE PREVENTED*
The ADA recommends the use of sealants to reduce the occurrence of caries• Sealants are most effective when applied early• Caries reduction in children with sealants ranges from
86% at one year to 79% at two years• Private dental insurance and Medicaid databases show
the use of sealants on 1st and 2nd molars is associated with reductions in the subsequent provision of restorative services
*Information from the ADA Sealant Recommendations
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RECOMMENDED SOLUTION
Introduce the DentaQuest “PreventistrySM Sealant Program”
Encourage members to have sealants place on 1st molars of children ages 6 and 7
Encourage members to have sealants place on 2nd molars of children ages 12 and 13
Provide the members with the tools they need to be successful
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Provider Web Portal Key
1. Portal Menus – The Administration, Claims/Pre-Authorizations, Patient, and Tools menus are displayed along the left side of the Client portal.
2. Welcome – This section contains the DentaQuest welcome message. 3. Health news – This section contains information and news articles of
interest. You can access the news articles by clicking on their respective links.
4. My Health Tools/Resources – This section contains links to various health resources.
5. Contact – This section contains DentaQuest’s contact information.6. Message Center – This section contains secure messages sent to you from
DentaQuest. NOTE: The Message Center only appears on your Home page if there are messages in your Inbox.
7. FAQ – This link opens the View FAQ page where you can view frequently asked questions.
8. Event Calendar – This link opens the Event Calendar.9. Related Documents – This link opens the Document List page.
Examples-ORM, Web Portal Training Guide.
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Provider Home Page
See Key on Next Slide
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Claim/Prior Authorization Menu Status Enter at least one
search Criteria: Member 12 digit
Subscriber id number
Member first name
Member last name Member’s date of
birth Select the dentist
from the Servicing Treating Dentist drop-down list
Claim/pre-authorization number field
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• Find the claim/pre-authorization status you want to view. In the Results section on the Claim/Pre-Authorization Status List page, click the Claim/Pre-Authorization Number link for the claim/pre-authorization status you wish to view. The Claim/Pre-Authorization Status Detail page appears.
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•Member Information – contains information about the patient
•Servicing Dentist Information – contains information about the serving dentist
•Claim/Pre-Authorization Information – contains information about the claim/pre-authorization
•COB Information-contain information about Coordination of Benefits, if available
•Service Line Information-contains information for each procedure code submitted
•Processing Policies-contains information on any applicable processing policies for the claim/pre-authorization
•File Attachments-lists any files that have been attached to the claim/pre-authorization
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Dental Claim Entry Basic Information –
enter the basic office information for the claim in this section.
Member Eligibility – enter member information in this section
Service Lines – enter the services related to the claim in this section File Attachments – attach any files you need for the claim in this section.
Optional
information – you can select the COB option, EPSDT option, Emergency option, enter optional accident information, and enter your NEA Attachment ID (if you are using the NEA to submit an attachment with this claim) in this section. A COB section only appears on the page if you select that option.
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Select the type of report you are attaching from the Report Type drop-down list
Accepted File Types (attachments)• Word document (.doc) • PowerPoint files (.ppt) • Excel files (.xls) Comma-separated values files (.csv) • Text file (.txt and .rtf) • Images (.gif, .jpg, .jpeg, .png, and .bmp) • Zipped files (.zip) • HTML files (.htm and .html) • PDF files (.pdf) • XML files • Orthocad files (.3dm)
Add File to claim/Pre-Authorization
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Dental Claim Confirmation Report
Allows you to open view and all claims/auths for the day only
The report must be run at the COB daily (you can save it or print it)
Leave the type blank to view all the claims/auth or narrow your search using the drop down selection of your choice
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GO GREEN WITH DIRECT GO GREEN WITH DIRECT DEPOSITDEPOSIT
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WHY ENROLL IN DIRECT WHY ENROLL IN DIRECT DEPOSIT?DEPOSIT?
Safer than checks, and helps eliminate forged, counterfeit, and altered checks.
Eliminates the risk of paper checks being lost or stolen in the mail.
Allows faster receipt of reimbursement. Allows faster access to funds; many banks credit direct deposits
faster than paper checks. Payments are easy and convenient. Valuable time savings for staff and avoidance of hassle
associated with going to the bank to deposit your check. Reduces the amount of paper in your office.
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HOW TO ENROLL IN HOW TO ENROLL IN DIRECT DEPOSITDIRECT DEPOSIT
To enroll providers must: Complete, sign and return the
authorization form Include a voided check with the
returned authorization form Return your enrollment form:
Via Fax: 262.241.4077 or Via Mail: 12121 North Corporate
Parkway Mequon, WI 53092
ATTN: PEC Department
Allow up to six weeks for your Direct Deposit process to be implemented
You will receive a bank note one check cycle prior to your first Direct Deposit payment
Providers participating in Direct Deposit will no longer receive paper remittance statements. Access your remittance statements on line
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DentaQuest Provider Relations DentaQuest Provider Relations TeamTeam
Waradah K. EargleProviders Relation Representative Toll-Free: 866-853-0657Fax: 540-656-2986Email: [email protected]
Bridget HengleProvider Relations RepresentativeToll-Free: 866-853-0657Fax: 804-327-6835 Email:[email protected]
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Accomack
Albemarle
Alleghany
Amherst
Appomattox
Arlington
AugustaBath
Bedford
Bland
Botetourt
Brunswick
Buchanan
Buckingham
Campbell
Carroll
Charlotte
ChesterfieldCraig
Culpeper
DickensonDinwiddie
FairfaxFauquier
Floyd
Fluvanna
Franklin
Frederick
Giles
Goochland
Grayson
Greene
HalifaxHenry
Highland
Wight
King WilliamLancaster
Lee
Loudoun
Louisa
Lunenburg
Mathews
Mecklenburg
Montgomery
Nelson
New Kent
Northampton
Northumberland
Nottoway
Page
Patrick
Pittsylvania
Prince
Pulaski
Rockbridge
Rockingham
Scott
Shenandoah
SmythSouthampton
Spotsylvania
Stafford
SurryTazewell
Warren
Washington
Westmoreland
WiseWythe
Hampton Newport
Virginia Beach
Amelia
Caroline
City
Clarke
Cumberland
Gloucester
Greensville
Hanover
Henrico
Isle of
James City
King and Queen
George
Madison
Suffolk
Orange
Powhatan
Edward
WilliamRappahannock
Richmond
Roanoke
Russell Sussex
York
Chesapeake
Charles
Essex
King
Middlesex
Prince Prince
NewsGeorge
Region Rep Name Assigned Counties
Central Bridget Hengle
Green CountiesAmelia, Brunswick, Buckingham, Charles City, Charlotte, Chesterfield, Cumberland, Dinwiddie, Goochland, Greensville, Halifax, Hanover, Henrico, Lunenburg, Mecklenburg, New Kent, Nottoway, Powhatan, Prince Edward, Prince George, Richmond, Surry, Sussex
Eastern Bridget Hengle
Red CountiesAccomack, Chesapeake, Essex, Gloucester, Hampton, Isle of Wight, James City, King and Queen, King William, Lancaster, Mathews, Middlesex, Newport News, Northampton, Northumberland, Southampton, Suffolk, Virginia Beach, Westmoreland, York
Northern Waradah Eargle
Pink CountiesArlington, Fairfax, Loudoun, Prince William
Northwest Waradah Eargle
Purple CountiesAlbemarle, Augusta, Bath, Caroline, Clarke, Culpeper, Fauquier, Fluvanna, Frederick, Greene, Highland, King George, Louisa, Madison, Nelson, Orange, Page, Rappahannock, Rockbridge, Rockingham, Shenandoah, Spotsylvania, Stafford, Warren
Southwest Bridget Hengle
Blue CountiesAlleghany, Amherst, Appomattox, Bedford, Bland, Botetourt, Buchanan, Campbell, Carroll, Craig, Danville, Dickenson, Floyd, Franklin, Giles, Grayson, Henry, Lee, Montgomery, Patrick, Pittsylvania, Pulaski, Roanoke, Russell, Scott, Smyth, Tazewell, Washington, Wise, Wythe
2012 VA Provider Relations Representative County Assignments
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DMAS Smiles For Children StaffDMAS Smiles For Children Staff Daniel Plain:
Dental Program Manager Direct Line: (804) 786-1567Fax: (804) 786-5799Email: [email protected]
Lisa Bilik: Dental Contract Monitor Direct Line: (804) 786-7956Fax: (804) 786-5799Email: [email protected]
Dr. Marjorie Chema:Dental ConsultantDirect Line: (804) 786-6635Fax: (804) 786-5799Email: [email protected]
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THANK YOU FOR PROVIDING THANK YOU FOR PROVIDING DENTAL CARE TO THE DENTAL CARE TO THE
UNDERSERVED UNDERSERVED SMILES FOR SMILES FOR CHILDRENCHILDREN MEMBERS IN MEMBERS IN YOUR COMMUNITY. WE YOUR COMMUNITY. WE
GREATLY APPRECIATE YOUR GREATLY APPRECIATE YOUR DEDICATION!DEDICATION!
