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A New Day For Oral Health In Virginia
Spring 2006
Provider Training Seminars
March 27 – 31, 2006
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Agenda
Welcome and Introductions Program Performance Updates Enrollee Eligibility Prior Authorizations Claims Enrollee Outreach Provider Resources Doral’s Provider Website Q & A Training Evaluation
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Training Objectives
Present updates regarding progress towards program goals and the latest changes to the program
Clarify and address issues related to eligibility Provide clarification regarding the prior
authorization process for hospital cases Outline the process for requesting
authorization for orthodontic treatment Review claims processes and procedures and
provide helpful hints for timely reimbursement
Discuss issues related to enrollee access and introduce new enrollee outreach activities
Provide a brief overview of provider resources Encourage greater utilization of the Doral
provider website
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Program Overview: Moving Successfully Toward the
Goals
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153 Additional Dentists Have Signed Up
The network has increased from 620 to 773620 to 773 individual providers with 1022 practice locations (As of February 28, 2006)
Six counties that previously had no participating dentists now have access to dental services:– Amelia– Brunswick– Charles City– Highland– Madison– Prince George
DMAS, Doral, the VDA and the Old Dominion Dental Society are continuing to enhance the Smiles For Children network
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Fee Schedule Increase – May 1, 2006
PROC. CODE DESCRIPTION
RATES BEFORE 7/ 1/ 05
RATES EFFECTIVE
7/ 1/ 05
RATES EFFECTIVE
5/ 1/ 06 PA/ PR* NOTES
D3310 ANTERIOR (EXCLUDING FINAL RESTORATION) 259.09 347.90 375.00
D3320 BICUSPID (EXCLUDING FINAL RESTORATION) 300.59 398.82 430.00
D3330 MOLAR (EXCLUDING FINAL RESTORATION) 393.70 513.07 679.00
D7140EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) 47.56 63.36 69.00
D7210
SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL FLAP AND REMOVAL OF BONE AND/OR SECTION OF TOOTH 77.94 110.63 128.00
D7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE 102.22 125.42 154.00
D7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY 154.85 190.00 213.00
D7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY 180.15 221.04 247.00
D7241REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS 200.00 245.40 266.00 PR Pre-Op X-Rays
D7250SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) 92.10 113.01 128.00
D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH 205.15 251.72 271.00 PR Pre-Op X-Rays and Narrative
D7283 PLACEMENT, DEVICE TO AID ERUPT 35.00 42.94 99.00 PR Pre-Op X-Rays and NarrativeD9248 NON-INTRAVENOUS CONSCIOUS SEDATION 55.00 67.49 110.00
The 2005 General Assembly approved increased funding for dental rates effective May 1, 2006. The Dental Advisory Committee decided to target endodontic and oral surgery codes as well as conscious sedation:
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Pediatric Dental Utilization
Preliminary analysis indicates an upward trend in the number of children receiving care
As of July 1, 2005, the percentage of enrolled providers who were treating Medicaid patients and filing claims was approximately 50%. Under the Smiles for Children program, this percentage is now approximately 75%
Through technology and improved customer service, enrollee access to dental providers has increased
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Eligibility
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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 message. Members may be in a waiver program and not eligible for dental benefits.
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Enrollee Eligibility
Issue: After receiving confirmation of eligibility, a provider receives a denial of claim. The denial reason indicates “Member Not Found”
How has the issue been addressed: DMAS and Doral are now exchanging eligibility information weekly. DMAS and Doral are making modifications to the eligibility file to ensure data is complete and accurate.
Providers are encouraged to contact Doral if a claim is denied inappropriately. If eligibility can confirmed, the claim will be reprocessed and paid accordingly.
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Tips on Members’ Eligibility Verification
It is recommended to verify eligibility in the month an appointment is scheduled.
When using the website to verify eligibility, it is recommended that the verification be completed within 3 days prior to the date of service
Patients who turn 21 are eligible through the end of the month of their birthday.
Orthodontic patients are covered for the duration of the treatment if she/he was eligible on the date of banding.
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Prior Authorization
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Minimal Authorization Requirements
Prior-Authorization Authorization and documentation
submitted before treatment begins Authorization decision provided
within 2 business days from the date the required documentation is received
For Hospital Dental services, authorization must be provided by Doral and the MCO, if applicable
– Authorization decision provided by Doral within 2 business days from the date the required documentation is received
– Upon approval by Doral, required documentation is forwarded to MCO if applicable. Authorization decision provided by MCO within 2 business days from receipt of information from Doral
Pre-payment Review Requires proper documentation
included with claim prior to consideration for payment
Option of requesting prior authorization if desired prior to rendering services
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OR Authorizations
Process to obtain an OR/SPU authorization: To ensure timely processing, requests should be submitted on an ADA claim form and
mailed to Doral at least 10 days prior to the date of service. Clinically emergent requests should be marked as such and faxed to 262-834-3575262-834-3575.
– Emergent care is defined as: A dental or oral condition that requires immediate services for relief of symptoms and stabilization of the condition; such conditions include severe pain; hemorrhage; acute infection; traumatic injury to the teeth and surrounding tissues; or unusual swelling of the face and gums.
Medical necessity should be clearly stated. Authorization of any services applicable to D9999 should be submitted along with the
request for SPU preauthorization. Doral is responsible for the coordination of the authorization process with the
Managed Care Organizations. Authorization determination letters for non-emergent care are mailed to the providers. Authorization determination letters for emergent care are faxed to the provider. Dentist/Dental Offices are responsible for ensuring the hospital receives authorization
information.
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Orthodontic Review Process
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Claims
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Four Methods to Submit Claims
Electronic via Doral’s Internet Website: Electronic via Clearinghouse:
• Affiliated Network Services (ANC)
HIPAA compliant 837D File Paper claims:
• Any ADA approved claim forms may be used (e.g. 1994, 2000, 2002-2004)
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Claims Processing
As a third party administrator, Doral pays claims upon receipt of funds from DMAS
Contractual guidelines state that clean claims are to be processed within 30 days if receipt. – A clean claimclean claim is defined as a complete claim that does not require any additional
information to process it.– Doral’s average claims processing turnaround time: 19.18 Days19.18 Days
Claims are processed according to processing cycle Cut-off for claims processing cycle is Cut-off for claims processing cycle is every Tuesday at 4 p.m.every Tuesday at 4 p.m. Processing cycle includes:
– Adjudication of claim– Reporting to DMAS– Approval of funds by DMAS
Checks are cut upon approval of payment from DMAS Checks are mailed upon receipt of funding from DMAS
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Claims Processing:Required Information
Most pertinent sections of the ADA form that must be completed in full in order to process your claims: Member’s information:
Name
Address
Date of Birth
Subscriber ID Number Record of services provided:
Date of service Fee Valid procedure code and a tooth number Tooth surface or quadrant if the procedure
code requires it Treating address Treating provider Billing entity’s information
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Orthodontic Claims
The start and billing date is defined as the date when the bands, brackets, or appliances are placed in the member’s mouth.
If a member becomes ineligible during treatment and before full payment is made, Doral will pay the balance for any remaining treatment.
The maximum payment is 1 initial 1 initial paymentpayment (D8080) and 3 quarterly 3 quarterly periodic billed orthodontic treatmentsperiodic billed orthodontic treatments (D8670).
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Claims Processing Calendar
Claim Received Prior to Cut-off:
Sun Mon Tue Wed Thu Fri Sat
1
2
3
4
5 6 Claim Received
7 Cut-off for 3/16 Run
8
9
10
11
12 13 14 15 Adjudicate
16 Deliver claims detail/invoice
17 VAMMIS entry Payment Approved
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19
20
21
22
23 Check Mail Date
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25
26
27 Payment Received Checks Mailed
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29
30 31
March
2006
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Claims Processing Calendar
Claim Received After Cut-off:
Sun Mon Tue Wed Thu Fri Sat
1
2
3
4
5 6
7 Cutoff for 3/16 Run
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CLAIM RECEIVED
9
10
11
12 13 14 Cutoff for 3/23 Run
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16
17
18
19
20
21
22 Adjudicate 23
Deliver claims detail/invoice
24 VAMMIS entry Payment Approved
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26
27
28
29
30 Check Mail Date
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1
2 3 Payment Received Checks Mailed
4 5 6 7
March
2006
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Tips to Ensure Timely Payment
Submit legible and correctly completed ADA claim forms
Alert Doral of any changes (i.e TIN, location, etc.)
Submit claims as soon after date of service as possible
Ensure that claim forms are filled out completely
When requested, be sure to use the treating location – not a P.O. Box
Use the patient’s name as shown on their ID Card/legal name – no nicknames
Claims must be submitted within 180 Days180 Days from the date of service or provider will face timely filing denials (Note: This is a change from the prior contract.)
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Enrollee Outreach
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Enrollee Access
Find A Provider:Find A Provider: A provider search feature on the DMAS and Doral websites. A dentist can be located within a certain mile radius from any given zip code.
Provider Directory:Provider Directory: The provider directory is posted on the DMAS and Doral websites. – A Provider Directory was mailed to recipients and all new recipients receive a
copy. This is the first provider directory ever provided to Medicaid enrollees. eIVR:eIVR: An enhanced automated phone system through a single 800
toll-free number. Members can verify eligibility and find a dentist through the automated system by entering a zip code. Services are available in Spanish and English.
Customer Service Representative:Customer Service Representative: Members may also speak directly with a customer service representative for additional assistance during extended customer service hours.
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Broken Appointments
Broken appointments are:– A major concern for DMAS, VDA, ODDS,
and Doral– Recognized as expensive for dentists– Lead to dentists unwillingness to participate in
the program
Information is needed to better track, trend, and understand the issue
Doral will use the information to:– Educate families regarding the importance of
appointments and compliance with treatment plans
Dentists can assist by completing the Broken Appointments Log and faxing to Doral’s Outreach Coordinator
Medicaid Transportation is available for dental appointments (contracted through the health plans)
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Appointment Reminder
Mailed to enrollees who have not accessed care
Postcard mailing campaign
– Alexandria
– Norfolk
– Richmond
– Roanoke
Targeted Mailing Date: 4th Quarter
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Provider Resources
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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.gov/dental-home.htm
or or
from the Doral website at:from the Doral website at:
http://www.doralusa.com
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Interactive Phone System
AVAILABLE 24 HOURS A DAY!AVAILABLE 24 HOURS A DAY!
Dentists can access:
Patient Eligibility
Limited Claims History
Fax Back Confirmation of eIVR call
Spanish Call Handling
With eIVR, information can be obtained instantly and easily.
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Enhanced Automated Phone System
Phone number to access this system: 1-888-912-3456, Option 11-888-912-3456, Option 1
To access eIVR, providers can login with:– Location ID Number– Last 4 digits of the location TIN– Full location TIN and Last Name
Patients eligibility can be verified on the eIVR along with limited claim history (codes: D0120, D0212, D0150, D0210, D0272, D274, 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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Keep Doral Updated
Accurate and up-to-date information is essential for appropriate referrals and claims payment.
Inform Doral of:– Changes to your address, phone and fax numbers– New practice locations– Changes to Tax ID Number(s)– Plans to retire or terminate
Alert Doral of broken appointments occurring in your practice Send an application for new providers joining your practice at least
30 days prior to the effective date and respond to Doral’s credentialing requests in timely manner
Share you experiences (positive or negative) with us Let us know what issues you would like addressed in our next
session
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Coming Soon!
Beginning Summer 2006, Doral will enhance its on-line services!
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Electronic Funds Transfer (EFT)
EFT permits the direct electronic deposit of Smiles For Children claim reimbursements into a bank account designated by the provider whether claims are filed electronically or on paper
Advantages of EFT include: – No lost checks or Post Office delay.
– Savings of administrative and overhead costs.
– No standing in line at the bank.
– Faster access to funds; many banks credit direct deposits faster than paper checks
– Easier reconciliation of payments with bank statements
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Provider Web-Site Enhancements
Ability for providers to view status of claims and prior authorizations
Provider information component, including:– On-line newsletter
– Program Information
Enhanced services will include:
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Contact Information
Doral’s Smiles For Children Staff:Doral’s Smiles For Children Staff:
Cheryl Harris: Direct Line:Direct Line: (804) 217-8344(804) 217-8344
Project Director Fax: (804) 217-8348Fax: (804) 217-8348
Email:Email: [email protected]
Anna Perez: Direct Line:Direct Line: (804) 217-8392(804) 217-8392
Provider Relations Representative Fax: (804) 217-8349Fax: (804) 217-8349
Email: Email: [email protected]
Kristen Fincher: Direct Line: (804) 935-8589Direct Line: (804) 935-8589
Outreach Coordinator Fax: (804) 217-8350Fax: (804) 217-8350
Email:Email: [email protected]
DMAS’ Smiles For Children Staff:DMAS’ Smiles For Children Staff:
Sandra Brown: Direct Line: (804) 786-1567Direct Line: (804) 786-1567
Dental Program Manager Email: Email: [email protected]
Lisa Bilik:Lisa Bilik: Direct Line: (804) 786-7956Direct Line: (804) 786-7956
Dental Contract MonitorDental Contract Monitor Email: Email: [email protected]
Dr. Stephen Riggs, DDS: Direct Line: (804) 786-6635Direct Line: (804) 786-6635
Dental Consultant Email: Email: [email protected]
Thank You!Thank You!
