HP Provider Relations October 2011 Dental Billing Guidelines

HP Provider Relations

October 2011

Dental Billing Guidelines

Dental Billing Guidelines October 20112

Agenda

– Objectives

– Provider Classifications

– Web interChange Overview

– Billing

– Third Party Liability

– Dental Policy

– Prior Authorization

– Claim Returns and Denials

– Electronic Health Records (EHR)

– ANSI 5010 Conversion

– Helpful Tools

– Questions


Session Objectives

At the end of this session, providers will understand the following:

–Difference between group, billing, dual, and rendering providers

–How to find out if a service is covered

–EHR program

–Implementation of the ANSI 5010 conversion

–How to avoid claim denials


Provider Classifications

– Billing Provider – A practitioner or facility operating under a unique taxpayer identification number (TIN). The TIN may be the dentist’s Social Security number or a federal employer identification number.

– Group Provider – Any practice with one or more dental practitioners sharing a common TIN. The group must have members linked to the business, and these members are identified as “rendering providers.”

– Rendering Provider – A practitioner employed by a group provider. The rendering provider actually performs the service. The IHCP makes payment to the group.

– Dual Provider – A provider that is both a billing and a rendering provider.

LearnWeb interChange Demo


Web interChange

– Allows for claim submission directly to HP

– Allows access to claim and member information

– Provides for secure data transmission

– Available 24 hours a day, seven days a week

– Free!


Web interChangeFunctions

– Member eligibility verification

– Claim submission including voids and replacement and electronic attachments

– Claim status inquiry

– Check/RA inquiry

– Provider profile inquiry, including access to enrollment documents

– Web administrator

– PA submission and inquiry


– Insert screen print here


Web interChangeMember eligibility

– On the home page, click Eligibility Inquiry

– Enter the member ID

– Enter the desired date of service

• Name and demographics

• Spend-down, level of care, Medicare

• TPL information

• Managed care information

• Restricted information

Prescriptions must be filled at the restricted pharmacy

• Amount of dental cap paid

• Dental benefit limitations


Required information


Required information


Web interChangeClaim submission

– Submit dental claims with as many as 50 details

– Add, copy, or delete details

– Rework denied claims

– Mail attachments separately

• Claims that require attachments suspend for 45 days waiting for the attachments to arrive

– Claim notes to reduce paper attachments

• 90-Day Provision

• Retroactive eligibility


Claim Notes Window

No attachme

nt needed!


Claim SubmissionClaim notes for 90-Day Provision

– Use claim notes instead of a separate attachment when submitting claims for the 90-Day Provision using Web interChange

– Document in the claim note segment:

• The phrase 90-Day Provision

• The member identification number (RID)

• Name of the Third Party Liability billed

• Dates of filing attempts


Required Information


Claim SubmissionCoordination of Benefits

– Coordination of Benefits (COB) information is required for TPL payments

– Click Benefit Information to open the COB window• Report the primary insurance information that applies

to the entire claim

– Access a TPL help guide on the Web interChange help page


Web interChangeClaim inquiry

– Inquire about previously submitted claims – even before they appear on an RA

– View the claim status within two hours of submitting the claim using the internal control number (ICN) that displayed when the claim was submitted

– Search by date range, member ID, or ICN

– When the claim displays, click on the ICN to retrieve the detailed information for the claim


Web interChangeVoids and replacements

– Access the Claim Inquiry function to void or replace claims

– A void is the cancellation of an entire claim, whether same day, same week, or post-financial

– A replacement is a change to an original claim, whether same day, same week, or post-financial


Web interChangeVoids

– Submit void requests electronically using the 837D electronic transaction or Web interChange

– Submit void requests for a previously paid claim submitted either electronically or via paper

– A void cancels the original claim

– The original claim being voided cannot be in a denied status

– There is no filing limit for void requests


Web interChangeReplacements

– A replacement claim can be submitted using the electronic 837D transaction or Web interChange

– A replacement also can be submitted on paper (also known as an adjustment)

– Check-related replacements must be submitted on paper

– There is a one-year filing limit for replacement requests

– If the date of service is over the one-year filing limit, utilize the paper Adjustment Request Form to correct the claim

Note: When the Replace This Claim feature is used more than one year after the date of service, a full recoupment may be applied to the claim


Web interChangeReplacements

– A replacement takes the place of the original claim

– When the IHCP receives a replacement claim, the replacement becomes a new claim (including attachments and claim notes)


Check for Remittance

Adviceevery week!


Web interChangeCheck/RA inquiry

– Inquire about previously received payments

– Find a check or electronic funds transfer (EFT) by searching within a date range or by searching for a specific check number

– When the basic check information displays, click on that line to see all the paid claims associated with that check


Web interChangeProvider profile

– Allows IHCP providers to view and edit profile information

– Includes the basic profile, service location information, and rendering provider information

– Update capabilities directly to provider files–Service location, Pay To, Mail To addresses

–EFT, add, delete or change

–Add specialties (group and rendering)

–Board of Directors

–Office manager


Web interChangeWeb administrator

– This function allows one person within the provider group to determine which users have access to specific functions of Web interChange

– The Web administrator can create, maintain, and delete user groups, reset passwords, and modify user information

– When a provider has a Web administrator, each user’s assigned logon ID and password are unique

• Logon ID is not a provider number


Web interChangePrior authorization inquiry and submission

– A requesting provider may inquire about all nonpharmacy prior authorization (PA) using the Web

• The PA request may have been submitted on paper, by telephone or fax, or through the Web

• The requesting provider and the named service provider may view a PA without the PA number

• All other providers must have the PA number to view the PA


Requesting and Service providers can use

member ID to check status. All other providers

must have the PA number to see

authorization status


Web interChangePrior authorization inquiry and submission

– This function allows providers to submit PA requests via the Web in a HIPAA-compliant format

– ADVANTAGE Health Solutions processes all PA requests for traditional Medicaid

– Dental services are self-referral for Care Select members

BillDental Services


2006 ADA Dental Claim Form

– Report billing and rendering NPIs on the dental claim form:

•Billing provider NPI field 49

•Rendering provider NPI field 54

– Rendering providers must be associated with the billing provider’s group and linked to that group in the provider profile

– The Remittance Advice (RA) identifies the rendering provider NPI on the detail line

– Chapter 8, Section 5 of the IHCP Provider Manual details the requirements for the ADA 2006 claim form


Managed Care Entities (MCEs)

– Dental services are carved-out of the risk-based managed care (RBMC) delivery system

– Dental providers who bill Current Procedural Terminology (CPT®) codes must submit claims using the electronic 837P transaction or the paper CMS-1500 claim form

• These claims must be submitted to the MCE after obtaining authorization

• Members with Traditional Medicaid or Care Select, including spend-down, and Level Of Care, are not enrolled in an MCE

CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


Billing a Member if Dental Cap Exhausted

– Dental Cap amount is $1,000• Applies each calendar year to members age 21 and above

• Does not apply to services rendered in a hospital setting

• After the member exhausts the $1,000 annual cap, the provider can bill member the usual and customary fees

Providers are encouraged to obtain a signed waiver once the $1,000 cap is showing exhausted on the eligibility verification

• PA will not override the dental cap of $1,000

– Example:

• On the date of service, the full $1,000 cap amount has been exhausted

• The provider renders services and the usual and customary charge equals $300

• The provider can bill the member for $300


Billing a Member if Dental Cap Exhausted

– When a claim is partially paid because of the dental cap limit, the provider can bill the member only for the difference between the IHCP rate and the amount actually paid

– Example:

• On the date of service, $800 of the cap amount has been exhausted ($200 of the cap amount remains)

• The provider renders services and the total IHCP rate is equal to $300

• The provider can bill the member for $100


Spend-down

– The spend-down amount is deducted from the first claim processed by IndianaAIM

– ARC 178 appears on the Remittance Advice when spend-down is credited on claims

– Providers may bill the member for the amount listed beside ARC 178

– Members are responsible to pay upon receipt of the Spend-down Summary Notice

BillThird Party Liability


Third Party LiabilityBilling tips

– If a third-party insurer makes a payment, do not include an explanation of benefits (EOB) with the claim

• Enter third-party liability (TPL) paid amount on the claim in field 35, or its electronic equivalent

– Include the EOB with the claim only when:

• The primary insurer denies a service, or

• The primary insurer allows the charges but pays zero dollars



– Always verify TPL information prior to providing services• The Eligibility Verification System (EVS)

identifies active TPL for eligible members

• Assignment of benefits should be on file for each member with TPL

– Providers may update TPL through Web interChange or by contacting the HP TPL Unit– Local (317) 488-5046

– Toll free 1-800-457-4510



– IHCP makes payment on TPL claims only when the total Medicaid rate for the entire claim exceeds the amount paid by the primary insurer for the entire claim

– IHCP reimbursement includes the lesser of the:• Difference between the IHCP rate and the

TPL paid amount for the entire claim

OR

• Amount billed on the claim


Third Party LiabilityBlanket denials

– What is a blanket denial?

• When a healthcare service is not a covered benefit for the insured, the IHCP accepts an EOB from the other insurer showing that the service is not covered

– What must the blanket denial EOB include?• Name of primary insurance carrier

• Information sufficient to identify the member

• Description of healthcare service

• Statement of noncoverage of the service

– Blanket denial EOBs can be used until the end of the calendar year of the date of service and must contain the same procedure code(s) that are billed on the claim


Third Party Liability90-Day Provision

– What is the 90-Day Provision?

– How to submit claims under the 90-Day Provision:–Write 90-Day Provision on the top of the claim

–Boldly make a note on the attachment:

• Date of the filing attempt

• The words no response after 90 days

• Member identification number (RID)

• Provider’s National Provider Identifier (NPI)

• TPL billed

• Name of Insurance company billed

– IHCP Provider Manual, Chapter 5, contains billing instructions


Third Party LiabilityInsurance carrier reimburses IHCP member

– Contact the TPL Unit to advise that payment was made to the member in error

– If unable to recover payment from a member or TPL, the provider should submit the claim under the 90-Day Provision

– Have the member sign an assignment of benefits authorization form prior to receiving services


Third Party LiabilityInsurance carrier reimburses IHCP member

– QMB members are eligible for Medicare and Medicaid

• The State pays the premium for Medicare Part B

– Two Types:

• QMB-Only – The IHCP pays “only” the Medicare coinsurance and deductible

QMB-Only members do not have dental coverage as Medicare does not cover dental services

• QMB-Also – The IHCP pays “also” for Medicare noncovered services in addition to the coinsurance and deductible

Services must be covered by Medicaid to be reimbursed


Third Party LiabilityImpact of QMB members

– Dental providers must have QMB-Only members sign a waiver prior to furnishing services

– The IHCP can pay for dental services for QMB-Also members for Medicaid-covered services


What is covered under the IHCP Program?

– Refer to the • IHCP Fee Schedule

• IHCP Provider Manual, Chapter 8, Section 5 to determine which Current Dental Terminology (CDT) codes are covered


Live demo

– The IHCP Fee Schedule is available on the IHCP Web site at indianamedicaid.com

– Included on the fee schedule:

• Pricing for procedure codes

• Code descriptions

• Code start and end date

• Prior authorization requirements for codes

Fee Schedule

http://www.indianamedicaid.com/

UnderstandDental Policy


Dental PolicyEvaluation codes

Use the following codes to bill for evaluations:

– D0120 – Periodic Oral Evaluation

• One visit per member every six months, irrespective of age

– D0150 – Comprehensive Oral Evaluation – new or established patient or D0160 Extensive Oral Exam

• Limited to one per lifetime, per member, per provider with an annual limit of two per member

– D0140 – Emergency Oral Exam • Enter the word Emergency in field 2 of the ADA

2006 dental claim form - Required for package E


Dental PolicyFluoride

– For fluoride services:

• D1203 – Topical application of fluoride – child (ages 1 through age 12)

• D1204 – Topical application of fluoride – adult (ages 13-20)

– Topical application of fluoride is not covered for members age 21 and above


Dental PolicyProphylaxis

– Use the following codes to bill for prophylaxis:

• D1120 – Prophylaxis - child (ages 1-11)

• D1110 – Prophylaxis - adult (ages 12 and older)

– The IHCP covers one cleaning every six months for members 20 years old and younger, and one cleaning every 12 months for members 21 years and older

– If the member is institutionalized, he or she is eligible for one cleaning every six months


Dental PolicyPeriodontal scaling and root planing

D4341 is limited to:

–Four units every two years for members aged 3-20

–Four units per lifetime for members aged 21 and older

–Four units every two years for institutionalized members


Dental PolicyPeriodontal scaling and root planing

– Claims submitted for procedure code D4341 must have required documentation to support the procedure

– Do not include quadrants on the detail lines

– Quadrant limitation verification is available on the EVS and is noted only after the fourth quadrant is paid

• EVS does not indicate the benefit limit until AFTER the full benefit is met (four units)

– Providers may also send an inquiry to Written Correspondence requesting paid claim history


Dental PolicySealants

– The IHCP only covers procedure code D1351 – Sealants, for permanent molars and premolars

– Reimbursement is limited to members younger than 21 years old, one sealant per tooth, per lifetime

– EVS provides tooth number detail for paid sealants


Dental PolicyMultiple restoration reimbursement

– The IHCP reimburses for only one restoration code per tooth using the same material when performed for the same member on the same date by the same dentist

– For example, the IHCP reimburses for only one of the appropriate procedure codes (D2140, D2150, D2160, D2161) for an amalgam restoration of primary tooth letter

– When a dentist performs multiple restorations on the same tooth, on the same day, and uses different materials on the same surface (without a second surface), the IHCP reimburses for a single surface restoration for each material

• The IHCP reviews these claims for medical necessity


Dental PolicyExtractions

– The IHCP reimburses 100 percent of the maximum allowed amount or the billed amount, whichever is less, for the initial extraction

– For multiple extractions within the same quadrant on the same date of service, the IHCP reimburses 90 percent of the maximum allowed amount for procedure code D7140 or the billed amount, whichever is less

– Bill only one tooth number per detail line


Claim SubmissionSupernumerary tooth extraction

– Effective January 1, 2010, the IHCP adopted the ADA tooth designations for supernumerary tooth extractions

– Eliminates the necessity to bill D7999


Claim SubmissionClaim notes for supernumerary tooth extraction

Permanent dentition – Supernumerary teeth are identified by the numbers 51 through 82, beginning with the area of the upper right third molar, following around the upper arch and continuing on the lower arch to the area of the lower right third molar

Tooth # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

“Super”# 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

Tooth # 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

“Super”# 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67


Claim SubmissionClaim notes for supernumerary tooth extraction

Primary dentition – Supernumerary teeth are identified by the placement of the letter “S” following the letter identifying the adjacent primary tooth (supernumerary “AS” is adjacent to “A”)

Tooth # A B C D E F G H I J

“Super”# AS BS CS DS ES FS GS HS IS JS

Tooth # T S R Q P O N M L K

“Super” # TS SS RS QS PS OS NS MS LS KS


Dental PolicyDentures

– The delivery date is the date of service for each service

– Providers may charge the member for dentures if the member is ineligible upon delivery

• A waiver is not required

– Providers must verify member eligibility prior to rendering services


Dental PolicyPA requirements for dentures

– Denture replacement requires PA

– Requests for relines or repairs may be approved if they will extend the useful life of a prosthesis

– Members 20 years old and younger do not require PA for dentures


Dental PolicyOrthodontia

– All orthodontic procedures require PA

– The IHCP only approves orthodontic procedures in cases of craniofacial deformity or cleft palate

– The patient must be diagnosed by a member of the American Cleft Palate – Craniofacial Association


Dental PolicyOrthodontia

– The diagnosis must include descriptive information of facial and soft tissue, skeletal, dental/occlusal, functionality, and applicable medical or other conditions

– The treatment plan must accompany the request for authorization

• The plan must show the phase and length of treatment

– The IHCP authorizes PA on a case-by-case basis


Dental PolicyGeneral anesthesia

D9220 and D9221 (General Anesthesia) is reimbursable

–Per 405 IAC 5-14-15, Medicaid reimbursement is available for general anesthesia

–Per 405 IAC 5-3-13, dental services rendered in an inpatient setting require prior authorization


Dental PolicyGeneral anesthesia

– General anesthesia for members 21 years of age and older may only be provided in a hospital (inpatient or outpatient) or ambulatory surgical center and must include documentation of the following in the patient’s record to be eligible for reimbursement:

• Specific reasons why such services are needed, including specific justification if such services are to be provided on an outpatient basis

• Documentation that the member cannot receive necessary dental services unless general anesthesia is administered

Example: A member may be unable to cooperate with the dentist due to physical or mental disability


Dental PolicyIV sedation

– Bill D9241 and D9242 for intravenous conscious sedation and analgesia

– The IHCP reimburses these codes in conjunction with services provided for oral surgery procedures only

– Maintain documentation in the patient’s file to support the service provided


Dental PolicyPosting payments and refiling claims

– Check all detail lines when posting IHCP payments to ensure all procedures are reimbursed

– Only resubmit denied details to avoid duplicate payments

– Resubmit using Web interChange

– Send paper claims to:

Dental ClaimsP.O. Box 7268Indianapolis, IN 46207-7271

AuthorizePrior authorization


Prior Authorization

– Mail PA requests for traditional Medicaid to:• ADVANTAGE Health Solutions-FFS

P.O. Box 40789 Indianapolis, IN 46240

– Or call 1-800-269-5720

– Fax is the preferred method for submitting PA requests• Fax ADVANTAGE at

1-800-689-2759


Prior Authorization – Care Select

– Fax is the preferred method for submitting PA requests

– Mail PA requests for Care Select Medicaid to:• ADVANTAGE Health Solutions

P.O. Box 80068Indianapolis, IN 46280Phone 1-800-269-5720 Fax request 1-800-689-2759

OR• MDwise

P.O. Box 44214Indianapolis, IN 46244-0214Phone 1-866-440-2449Fax request 1-877-822-7186

DenyCommon Returned Claims and Denial Reasons


Return to Provider (RTP) Claims

– If you receive claims back with a cover letter, your claims have not been entered into the claims processing system

– The following are examples of the top reasons claims are returned to providers

Invalid NPI– Verify that all paper claim submissions contain the correct NPI

in the following fields of the ADA 2006 claim form• Field 49, Enter the NPI of the Group or Billing Provider

• Field 54, Enter the NPI of the Rendering provider


RTP Claims

Illegible handwriting– HP will accept claims that are handwritten

• If submitting handwritten paper claims, be sure the writing is clearly legible and all information is inside the field line

– Do not use red ink

RID number missing– Verify that all paper claim submissions contain the RID in field

15 of the ADA 2006 dental claim form

– Claim field instructions are found in Chapter 8, Section 5 of the IHCP Provider Manual for the ADA 2006 claim form


Exact Duplicate

– Cause• When the claim being processed is an exact duplicate of a claim(s) on the history file in

a paid status

– Resolution• Review claims submitted to identify claim in paid status

Review Claims Inquiry inquire on Web interChange

Review past-dated Remittance Advices

Edit 5001


Procedure code vs. age restriction

– Cause• Procedure code listed is designated for a particular age range that does not coincide

with the age of the member on the claim

For example, if a member is 10 years old and a D1110 is billed, this edit will cause the claim line to deny

– Resolution• Research the age and benefit limitations detailed in the IHCP Provider Manual in

Chapter 8, Section 5

Edit 4034


Dates of service not on PA master file

– Cause• The procedure code listed requires PA, and no PA is on file in the IndianaAIM claims

processing system

– Resolution• Contact the PA vendor (ADVANTAGE Health Solutions or MDwise Care Select) and

request PA

Edit 3001


Recipient name and number disagree

– Cause• The member number and the member name on the claim do not match what is listed

on the recipient eligibility

– Resolution• Check the Eligibility Inquiry on Web interChange and verify all information on the claim

matches the eligibility information exactly

Edit 0513


Recipient covered by private insurance– Cause

• The claim does not contain either (1) indication of the primary insurance payment or (2) a copy of the primary insurance EOB form

– Resolution• Verify eligibility using Web interChange to determine what primary insurance should be

billed; after obtaining payment or denial from the primary carrier, rebill for adjudication through the IHCP

• Providers can either file the claim:Using Web interChange when a payment has been made (no attachment needed)Refiling the claim on the Web interChange with a paper attachment using the

attachment processRefiling the claim on a paper claim form including the primary EOB behind the claim

form• When primary insurance denies or pays zero on a claim, providers will need to include

the primary insurance EOB with their claim

Edit 2504

DescribeEHR Incentive Program


– The American Recovery and Reinvestment Act (Recovery Act) of 2009 provides for incentive payments for eligible professionals (EPs), and eligible hospitals (EHs) who are meaningful users of certified electronic health record technology

– EHR Incentive Program runs from 2011-2021

– EPs register for the incentive program through a two-step process:1. Providers must register at the CMS Registration and Attestation system and select

Indiana as their state

2. Register their EHR system using the Provider Profile feature of Web interChange

– Ensure your National Plan and Provider Enumeration System (NPPES) and Provider Enrollment, Chain, and Ownership System (PECOS) records are updated and accurate

EHR Incentive ProgramEligibility information


– Per federal rule, EPs must register for EHR incentive payments no later than calendar year (CY) 2016

– EPs must meet patient volume criteria as follows:• Minimum 30 percent patient volume attributable to Medicaid-funded services

OR• Practice predominantly in a federally qualified health center (FQHC) or rural health clinic (RHC) and have a minimum 30 percent patient volume attributable to needy individuals

EHR Incentive ProgramEligible professional (EP)


EHR Incentive Program

– The maximum incentive payment to an EP is $63,750, over a six-year period

– EPs must begin receiving payment no later than CY 2016

– The last year an EP can receive payments is 2021Provider EP EP-

Pediatrician

Patient Volume 30% 20-29%

Year 1 $21,250 $14,167

Year 2 8,500 5,667

Year 3 8,500 5,667

Year 4 8,500 5,667

Year 5 8,500 5,667

Year 6 8,500 5,667

Total Incentive Payment

$63,750 $42,500

PrepareANSI version 5010


HIPAA 5010

– The mandatory compliance date for ANSI version 5010 for all covered entities is January 1, 2012

– If submitting claims to the IHCP, you need to prepare for these upgrades to prevent delay in payment

– Indiana Health Coverage Programs (IHCP) 5010 Companion Guides and Upcoming Changes document are available at provider.indianamedicaid.com• Upcoming Changes document contains only

segments that are updated, added, or deleted

http://www.provider.indianamedicaid.com/


HIPAA 5010

Transactions affected that may impact you:

– Dental claims (837D)

– Eligibility verifications (270/271)

– Claim status inquiry (276/277)

– Electronic Remittance Advices (835)

– Prior authorizations (278)


Testing Information

– All trading partners currently approved to submit 4010A1 will be required to be approved for 5010

– All software products used to submit 4010 must be tested and approved for 5010

– Testing began January 2011 and includes:• Clearinghouses, billing services, software vendors, individual providers, and

provider groups

– Providers that exchange data with the IHCP using an IHCP- approved software vendor will not need to test

– Each trading partner is required to submit a new Trading Partner Agreement


What You Need To Do

– If you bill IHCP directly:

• Begin the process to upgrade to the ANSI 5010

– If you are using a billing service or clearinghouse:

• Find out if they are preparing for the HIPAA upgrades to ANSI version 5010

• IHCP Companion Guides will be available during the fourth quarter of 2010

– Questions should be directed to [email protected]

OR

– Call the EDI Solutions Service Desk• 1-877-877-5182 or (317) 488-5160

– Watch for additional information on the testing process, revised IHCP Companion Guides, and the schedule for transaction testing on this mandated initiative in bulletins, banner pages, and newsletters at indianamedicaid.com


Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at indianamedicaid.com

– IHCP Provider Manual

– IHCP Fee Schedule

– Customer Assistance• 1-800-577-1278, or

• (317) 655-3240 in the Indianapolis local area

– Written Correspondence

• P.O. Box 7263

Indianapolis, IN 46207-7263

– Provider field consultant


Q&A

Documents

HP Provider Relations October 2011 Dental Billing Guidelines