Fall Provider Seminars 2019

October 17, 2019 Sioux City, Iowa

October 18, 2019 Johnston, Iowa

October 25, 2019 Cedar Rapids, Iowa

Government Programs

Dental Wellness Plan and Hawki

Overview

• Changes for State fiscal year 2020 Dental Wellness Plan benefits

• Healthy Behaviors

• Cultural Competencies

• Electronic Billing

• Appeal Process and Exception to Policy

• Outreach and Care Coordination

State Fiscal Year 2020 DWP Benefits

Full Benefits

$1,000 Annual benefit maximum (ABM) July 1-June 30

Excluded services (dentures, diagnosis and prevention, emergent and sedation codes with oral surgery)

Basic Benefit

ADDED dentures, adjustments and relines, complete intraoral series

services do not have to be emergent

Eliminated the requirements for a few Prior Authorizations of Services

Healthy Behaviors

1. Preventive Service

2. Risk Assessment

• Member Self Assessment

• Provider Risk Assessment through PreViser

Requirements:

Cultural Competency Training

Federal 438 Regulations Requirements

• Requires providers to complete cultural competency training• Provider needs to self attest during the credentialing and re-

credentialing process

Electronic Billing Requirement

Who does this apply to?

• All Medicaid providers will be required to submit claims and attachments electronically

–Medicaid Providers includes Fee for Service (FFS), Dental Wellness Plan (DWP) and Hawki

• This includes all dentists as of February 2020

–See Information Letters #2045-FFS-D

https://dhs.iowa.gov/sites/default/files/2045-FFS-D_Electronic_Billing_Requirements.pdf?101620191407

Why is this happening?

• The Iowa Medicaid Enterprise is requiring all managed care organizations to require providers to bill electronic

• Eliminates paper claims and attachments reducing administrative burden

• Processing time for claims will be decreased and providers will be reimbursed faster

Implementation

• Only electronic claims will be processed after February 1, 2020

• Any claims that are mailed in after this date, will be denied

• Options for Billing Electronically:

–ABILITY PC-ACE Pro (free software from IME)

• Contact Provider Services at: imeproviderservices@dhs.state.ia.us or 1-800-338-7909

• Delta Dental website: www.deltadentalia.com

–Electronic Data Interchange Clearinghouse

• Any supporting documentation needed to process a claim will also need to be submitted electronically

Appeal and Exception to Policy (ETP)

DWP and Hawki Appeal

• Appeal form on the DDIA Website

• Must have member’s signature if provider is submitting the appeal

• DDIA has 30 days to review

–Denial or limited authorization of a requested service, including the type or level of service

–Reduction, suspension, or termination of a previously authorized service

–Denial, in whole or in part, of payment for a service

–Failure to provide services in a timely manner, as defined by the State

DWP and Hawki Exception To Policy

• ETP form on the DDIA Website

• DDIA reviews and send to Iowa Medicaid for final approval

–There’s an extreme need for the services

–There’s exceptional circumstances to justify the need

Outreach and Care Coordination

Outreach & Care Coordination

Continuous Outreach

Newly Eligible

Utilization

Healthy Behaviors

Basic

Target Populations

Pregnant Women

Diabetic Members

DDIA Website Tips & Tricks

To find a remaining

annual maximum

for member, log in

to the specific

member. Go to the

Eligibility and

Benefits Report.

Take the amount allowed for the year and subtract the Regular Annual Maximum used Year to Date.

Use one of these options when checking Claims Status. **** If the claim does not show “Paid, Pending, or Processed” here, we are not able to see it at DDIA. Please check the spelling, DOB, etc. before attempting to refile. If you are filing electronically and the claim did not go through, you should receive an error report from your clearinghouse.

#1 shows from a particular member’s screen

Screen #2 shows the same information using your provider login.

Benefits and Frequencies can be located for each member under the “Benefits and Frequencies” tab. A claim history for anything submitted in the previous 5 years will be shown under the “Claim History” tab.

Use the Resources tab to locate necessary forms.

To change a Pre-Estimate to a Pay On Auth, click on the number in the screen below.

CDT and Policy Changes - 2020

New CDT Codes - 2020

Deleted codes

6

New codes 37

Revisions 20

Deny vs. not billable to the patient

Denied/Deny: If the benefit for a procedure or service is denied, the procedure or service is not a benefit of the patient’s coverage and the approved amount is collectable from the patient. Example: the third cleaning

Not billable to the patient: If the fee for a procedure or service is not billable to the patient, it is not benefited by Delta Dental or collectable from the patient by a participating dentist. Example: local anesthesia given with a filling

New CDT Codes

D0419 – Assessment of salivary flow by measurement

Limited to one every three years. Subsequent submissions are not billable to the patient within 12 months and DENIED between 12 and 36 months.

D1551, D1552 and D1553

D1551 - re-cement or re-bond bilateral space maintainer – maxillary

D1552 - re-cement or re-bond bilateral space maintainer – mandibular

D1553 - re-cement or re-bond unilateral space maintainer – per quadrant

Deleted D1550 - re-cement or re-bond space maintainer

a. One recementation or re-bonding is allowed per space maintainer.

b. Benefits for subsequent requests are DENIED

D1556, D1557 and D1558

D1556 - removal of fixed unilateral space maintainer – per quadrant

D1557 - removal of fixed bilateral space maintainer – maxillary

D1558 - removal of fixed bilateral space maintainer – mandibular

Deleted D1555- removal of fixed space maintainer

a. Fees for removal of fixed space maintainer by the same dentist/dental office who placed appliance are not billable to the patient anytime following placement of space maintainer.

b. Fees for removal of a fixed space maintainer by a different dentist/office than who placed the appliance are DENIED.

D2753 - crown – porcelain fused to titanium or titanium alloys

Removable partial dentures

D5284removable unilateral partial denture – one

piece flexible base (including clasps and teeth) – per quadrant

D5286removable unilateral partial denture – one piece resin (including

clasps and teeth) – per quadrant

Implant supported crowns

D6042 - implant

supported crown -porcelain fused to

predominantly base alloys

D6083 - implant

supported crown -porcelain fused to

noble alloys

D6084 -implant

supported crown -porcelain fused to

titanium or titanium alloy

D6086 - implant

supported crown -predominantly base

alloys

D6087 - implant

supported crown -noble alloys

D6088 - implant

supported crown -titanium/titanium

alloys

Implant supported retainer for Fixed Partial Denture (FPD)

D6120- implant

supported retainer –porcelain fused to

titanium and titanium alloys

D6121 - implant

supported retainer for metal FPD –

predominantly base alloys

D6123 - implant

supported retainer for metal FPD – titanium and titanium alloys

D6098 - implant

supported retainer -porcelain fused to

predominantly base alloys

D6099 - implant

supported retainer for FPD -porcelain fused to noble

alloys

D6195 - abutment supported retainer - porcelain fused to titanium and titanium alloysA metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from an abutment on an implant.

D6243 - pontic - porcelain fused to titanium and titanium alloys

D6753 retainer crown - porcelain

fused to titanium and titanium alloys

D6784

retainer crown ¾ - titanium and titanium alloys

Retainer crowns

D7922 - placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site

a. Placement of an intra-socket biological dressing to aid in hemostasis or clot stabilization is considered part of the extraction and/or post-operative procedure.

b. A separate fee is not billable to the patient.

Orthodontic appliance repair

D8696 - repair of orthodontic appliance – maxillary

Does not include bracket and standard fixed orthodontic appliances. It does include

functional appliances and palatal expanders.

D8697 - repair of orthodontic appliance – mandibular

Does not include bracket and standard fixed orthodontic appliances. It does include

functional appliances and palatal expanders.

Policy: This procedure is generally excluded by group/individual contract. In the absence of a contractual exclusion, benefit as submitted.

Deleted D8691 - repair of orthodontic appliance

Re-cement or re-bond fixed retainer

D8698 - re-cement or re-bond fixed retainer – maxillary

D8699 - re-cement or re-bond fixed retainer – mandibular

a. This procedure is included in the orthodontic case fee. A separate fee is not billable to the patient anytime following placement of the fixed retainer by the same dentist/dental office. In cases where there are excessive or continuous recements and rebonds, individual consideration can always be given.

b. In the case where a different dentist/dental office is recementing/rebonding the fixed retainer a separate benefit may be given once in a lifetime and benefits for any additional D8698 are DENIED.

Deleted D8693 - re-cement or re-bond fixed retainer

Repair of fixed retainer

D8701 - repair of fixed retainer, includes reattachment – maxillary

D8702 - repair of fixed retainer, includes reattachment – mandibular

a. This procedure is included in the orthodontic case fee. A separate fee is not billable to the patient within 24 months following placement of the fixed retainer by the same dentist/dental office. In cases where there are excessive or continuous repairs, individual consideration can always be given.

b. D8701/D8702 submitted after 24 months of placement is DENIED.

c. In the case where a different dentist/dental office is recementing/rebonding the fixed retainer a separate benefit may be given once per lifetime and benefits for any additional D8701/D8702 are DENIED.

Delete D8694 - repair of fixed retainer, includes reattachment

Replacement of lost or broken retainer

D8703 - replacement of lost or broken retainer – maxillary

Does not include bracket and standard fixed orthodontic appliances. It does

include functional appliances and palatal expanders

D8704 - replacement of lost or broken retainer – mandibular

Does not include bracket and standard fixed orthodontic appliances. It does

include functional appliances and palatal expanders

Policy:

Benefits are DENIED within 12 months of completion of orthodontic treatment. After 12 months, benefit once per lifetime

Deleted D8692 – replacement of lost or broken retainer

D9997 - dental case management – patients with special health care needs

Special treatment considerations for patients/individuals with physical, medical, developmental or cognitive conditions resulting in substantial functional limitations, which require that modifications be made to delivery of treatment to provide comprehensive oral health care services.

Policy:

The fees for patients with special health care needs are considered administrative and used to identify services provided to a particular type of patient and are not billable to the patient.

Deleted Codes6 deleted codes for 2020

Deleted Codes

D1550 - re-cement or re-bond space maintainer

D1555 - removal of fixed space maintainer

D8691 - repair of orthodontic appliance

D8692 – replacement of lost or broken retainer

D8693 - re-cement or re-bond fixed retainer

D8694 - repair of fixed retainer, includes reattachment

Modified Codes20 codes for 2020

D1510, D1520, D1575

D1510 - space maintainer – fixed, unilateral – per quadrant

D1520 - space maintainer – removable,- unilateral – per quadrant

D1575 - distal shoe space maintainer – fixed, – unilateral – per quadrant

D2794-crown titanium/titanium alloy

D5213, D5214, D5221-5224

Wording change – replaced conventional clasps with retentive/clasping materials to match prior year edits

No policy change.

Example:

immediate maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps retentive/clasping materials, rests and teeth)

D6066, D6067, D6076, D6077

Wording change – removal of reference to titanium/titanium alloy as well as the word metal.

D6066 - Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal alloys)

D6067 Implant supported metal crown (titanium, titanium alloy, high noble alloys metal)

D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble alloys metal)

D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble alloys metal)

D6094 - abutment supported crown titanium ortitanium alloys

D6194 - abutment supported retainer crown for FPD metal titanium or titanium alloysA retainer for a fixed partial denture that gains retention, support, and stability from an abutment on an implant. May be cast or milled

D6214 - pontic - titanium or titanium alloys

D6794 - retainer crown - titanium and titanium alloys

New Policy

D9941 – Fabrication of athletic mouthguard

Benefits for fabrication of athletic mouthguard are DENIED unless covered by group/individual contract.

a. Benefit once every 24 months for patients 18 and younger.

b. For patients over age 18, benefits for D9941 are DENIED.