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HOW TO

OPTIMIZE

YOUR MEDICAID

DENTAL BILLING

www.cns.state.va.us/dmas

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Training Objectives• How to use the provider manual to

assist with questions in regards to covered services, billing and utilization review.

• How to properly submit claims and resolve claim problems including:– Adjustments and Voids– Resolving your own rejects and denials

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Participating Provider

• Licensed to practice dentistry in the Commonwealth of Virginia (or in the state in which he or she practices)

• Meets the standards of requirements set forth by DMAS and has a current, signed participation agreement with DMAS.

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Provider Enrollment Unit

For enrollment agreements, change of address and enrollment questions :

First Health Provider Enrollment UnitP. O. Box 26803

Richmond, VA 23261

Helpline 804-270-5105Toll Free 804-829-5373Fax 804-270-7027

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DMAS Order DeskCommonwealth Martin

1700 Venable StreetRichmond, VA 23223

Order Desk 804-780-0076Fax Number 804-782-9876

Medicaid Dental Manual

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Eligibility:Medicaid or Medallion II HMO

Recipients enrolled in the traditional Medicaid Program will be identified by a Virginia Medicaid Eligibility Card.

Eligibility can be verified by AVRS, Provider Helpline or other system options.

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CASE I.D. NUMBERPLUS

I.D. NUMBER

123-456789

01-502-303-804-605-4

Recipient Eligibility Card

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BIRTH DATE SEX

FMMMF

10 31 195309 22 195104 05 197501 14 197911 02 1990

Recipient Eligibility Card

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CBAAA

DOE, JANEDOE, SAMDOE, TEDDOE, ALLENDOE, ANN

SI NAME

THE FOLLOWING INDIVIDUALSARE ELIGIBLE THROUGH THELAST DAY OF

JUNE 2001

Recipient Eligibility Card

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Recipient Eligibility CardSpecial Indicator Code (SI)

• A Under 21 -No co-pay exists.

• B Individuals Receiving Long-Term Care Services or Hospice Care - No co-pay is required for any service.

• C All Other Recipients- Co-pays apply for inpatient hospital admissions, outpatient hospital clinic visits, clinic visits, physician office visits, eye exams, prescriptions, home health visits, and rehab service visits.

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THE FOLLOWINGINDIVIDUALSARE ELIGIBLE FROM

06 01 0106 01 0106 01 0106 01 01 06 01 01

BEGIN DATE

Recipient Eligibility Card

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C

BAAA

DOE, JANEDOE, SAMDOE, TEDDOE, ALLENDOE, ANN

SI NAME

THE FOLLOWING INDIVIDUALSARE ELIGIBLE THROUGH THELAST DAY OF JUNE 2001

Recipient Eligibility Card

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CASE I.D. NUMBERPLUS

I.D. NUMBER

123-456789

02-302-3

CARRIER BEGIN DATE

06 01 0106 01 01

001001

Recipient Eligibility CardInsurance Information

Chap. 3

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12345678A12345678A

JH

TYP POLICY # / MEDICARE #

Recipient Eligibility CardInsurance Information

Chap. 3

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Eligibility:Medicaid or Medallion II HMO

You will be able to identify recipients enrolled in a Medallion II HMO by their Member ID Card.

Those enrolled in a Medallion II HMO will carry a card bearing the name of one of following plans: Carenet, Sentara Family Care, Healthkeepers or Virginia Premier Health Plan.

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Important Contacts:

• REVS- Medicaid Eligibility

• Provider Call Center

• Billing Inquiries

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AUTOMATED RESPONSE SYSTEM

• Automated Response System (ARS)* Claim Status* Check Status* Recipient Eligibility-REVS

800-884-9730 804-965-9732 804-965-9733

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PROVIDER CALL CENTER

Claims, covered services, billing inquiries:

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

600 East Broad Street, Suite 1300

Richmond, Virginia

800-552-8627

804-786-6273

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BILLING INQUIRIES

Customer ServicesDepartment of Medical Assistance Services

600 East Broad Street, Suite 1300Richmond, VA 23219

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Dental Treatment Coveredby Virginia Medicaid

• Dental services for recipients under 21 years old

• Limited oral surgery for recipients age 21 and older, when pre-authorized by DMAS Medical Support

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PRE-AUTHORIZATIONUnder Age 21

Department of Medical Assistance Services

DentalP.O. Box 27431

Richmond, Virginia 23261-7431

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PRE-AUTHORIZATIONAge 21 and Over

Department of Medical Assistance Services

Medical Support600 East Broad Street,

Suite 1300Richmond, Virginia 23219

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Dental Billing

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As a Participating ProviderYou must -

Accept, as payment in full, the amount paid by Medicaid.

Bill any and all other third-party carriers.

Determine the patient's identity.

Verify the patient's age.

Verify the patient's eligibility.

Maintain records for minimum 5 years.

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Claims Address

Department of Medical Assistance ServicesDental

P. O. Box 27431Richmond, VA 23261-7431

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TIMELY FILING

• ALL CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR FROM THE DATE OF SERVICE

EXCEPTIONS: Retroactive Eligibility/Delayed Eligibility Previously rejected or denied claims

• Submit claims with documentation attached explaining the reason for delayed submission.

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1994 ADA Billing Instructions

1994 ADA

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Locator 1

1.Dentist’s pre-treatment estimate

Dentist’s statement of actual services

Provider ID #

Provider ID # - Enter the seven-digit Medicaidprovider ID number of the billing provider.

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Locator 22.

Medicaid Claim

EPSDTPrior Authorization #Patient ID #Patient ID # - Enter the 12-digit number that is found

on the recipient’s Medicaid Identification Card. An“A” in the Special Indicator (SI) Block of the ID card indicates the recipient is under 21 and eligible for dental services through the period the card is valid. Recipient’s birth date is indicated for age validation.

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Locator 3

3. Carrier name and address

Carrier Name and Address - This block is used forthe transmission code. Enter 181 for Original Claim, 182 for Adjustment, or 184 for Void.

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Locator 44. Patient name

first m.i. last

Patient’s Name - The last name and first name of the patient must be entered as they appear on therecipient’s eligibility card.

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Locator 7: Conditional

7. Patient birth date MM DD YYYY

Patient’s Birth Date - If the transmission code entered in Block 3 is 182 or 184, enter the 3-digitcode for the reason for the adjustment or void. Digit 1 should be placed in the MM, digit 2 in the DD, and digit 3 in the YYYY.

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Locator 8 : Conditional8. If full time student school

city

If full time student - If the transmission code entered in Block 3 is 182 or 184, enter the referencenumber (found on the remittance voucher) of theclaim that is being adjusted or voided.

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Locator 30-32: Conditional

30. Is treatment result of occupational illness or injury?31. Is treatment result of an auto accident?

NO YES

Is treatment result of occupational illness or injury? - When the patient has other dental coverage, Medicaid is a last-pay program. Therefore if treatment is required due to an accident, check yes in this block and note under the Remarks section all availableinformation concerning the accident and possibility of other insurancecarriers. Leave blank if treatment is not the result of an accident.

32. Other accident?

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Locator 37

• Tooth # or letter

• Surface

• Description of service

• Date Service Performed

• Procedure Number

• Fee

• For administrative use only

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Locator 37: Tooth # or LetterTooth# or letter

Tooth # or letter- Enter the tooth number (1-33)or (A-T) or quadrant (UL, UR, LL, LR) relatingto the procedure being performed (if applicable)

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Locator 37: SurfaceSurface

Surface- Enter the surface of the tooth (if applicable). Refer to the Medicaid Dental Manualfor the valid surface codes.

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Locator 37: Description of Service

Description of service(including x-rays, prophylaxis, materials, etc.

Description of Service- Enter the 9-digit authorization number assigned by DMAS afterapproval of any pre-authorized service. Refer tothe Dental Manual for the special procedures requiring pre-authorization.

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Locator 37: Date Service Performed

Date serviceperformedMo. Day Year

Date Service Performed (month/day/year) -Enter the date of service for each individual lineitem. Do not leave this block blank.

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Locator 37: Procedure NumberProcedure number

Procedure Number - Enter the number of units and the 5-digitdental procedure code performed.

(Use the codes listed in Appendices B and C of theDental Manual.) For Dental Clinics associated withFederally Qualified Health Centers and Rural HealthClinics, enter the DMAS assigned dental encountercode. Only nine lines can be submitted per claim form due to system constraints. If more than nine lines are submitted, the entire claim will be returned.

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Locator 37: Fee Fee

Fee - Enter your usual and customary charge forthe procedure performed.

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Locator 37: For Administrative Use Only

Foradministrativeuse only

For Administrative Use Only-If a recipient has other dentalcoverage (e.g. Champus, schoolinsurance, etc.) and this insurancehas paid a portion of the care, enterany payment from primarycarrier other than Medicare. Includea copy of the explanation ofbenefits from the other carrier withthe invoice.

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Locator 38: Conditional 38. Remarks for unusual services

Remarks For Unusual Services - If treatment is related to an accident, provide any additional information in the block. See instructions for Blocks30-32. Please note that any information that is placed in this block or any document that is attached to the claim will cause all lines of the claim to pend for manual review even if the “Remarks” or the attachment applies to one line of the claim.

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Locator 38: Continued

Therefore, if you have multiple lines of a claim to complete and only one line requires that you provide DMAS with additional information, (either in “Remarks” or with an attachment) you should bill the one line on a separate claim form so that all lines of your claim will not pend unnecessarily and cause a delay in reimbursement.

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Locator 3939. I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures.

>______________________________________________________________

Signed (Treating Dentist) License Number Date

Signature of dentist, license number, and date.

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ADJUSTMENT OR VOID INVOICE

FOR ADA 1994

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Instructions

The ADA (1994) form can be used for adjusting or voiding payments previouslyapproved on Remittance Vouchers. Only one line can be billed on an ADA (1994) form used for adjustments or voids. Continue to follow the instructions in the Dental Manual for submitting claims. Specific information for adjustments or voids:

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Locator 3

• Carrier Name and Address- – Enter code 182 to indicate adjustment– Enter code 184 to indicate a void

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Locator 7

• 528- correcting procedure/service code

• 530- correcting charge• 538- correcting tooth• 539- correcting site

Patient’s Birth Date -Enter the first digit of thecode in the MM, thesecond digit in the DD and the third digit in the YYYY.

Adjustment Codes

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Locator 7

• 552- Date of service correction

• 544- Provider ID correction

• 545- Recipient ID correction

Patient’s Birth Date -Enter the first digit of thecode in the MM, thesecond digit in the DD and the third digit in the YYYY.

Void Codes

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Locator 8

• If Full Time Student– Enter the reference number of the claim that is

being adjusted or voided. (This information can be found on the Remittance Voucher.)

REMITTANCE VOUCHERSections of the Voucher

APPROVED - for payment.

PENDING - for review of claims.

DENIED - no payment allowed.

CREDIT- Adjusted claims creating a positive balance.

DEBIT - Adjusted/Voided claims creating a negative balance.

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REMITTANCE VOUCHERColumns of the Voucher

Recipient's Identification Number

Reference Number

Visits/Units/Studies

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Thank

Youwww.cns.state.va.us/dmas