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Massachusetts League of Community Health Centers Meeting
AGENDA MassHealth Team Introduction
MassHealth Updates Third Party Liability Claims
Electronic Initiatives
Dentures
MassHealth Claim Denials Top Five Reasons / How to Avoid Denials
Health Safety Net Denials (HSN)
Ordering and Referring
Outreach Age One
Fluoride in a Medical Setting
Sealant Program
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Introducing the MassHealth TeamDentaQuest
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Marianne Leahy – Vice President, Network ManagementPhone: 617-886-1206E-mail: [email protected]
Keishia Lopez – Provider Relations Rep. (Boston and Southern MA)Phone: 617-886-1727E-mail: [email protected]
Daniel Archambault – Provider Relations Rep. (Northern MA)Phone: 617-886-1736E-mail: [email protected]
DentaQuest Provider Relations
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Tracy Chase – Contract DirectorPhone: 617-886-1310E-mail: [email protected]
Arielis De LaRosa – Member Intervention SpecialistPhone: 617-886-1726E-mail: [email protected]
Felicia Moses – Intervention SpecialistPhone: 617-886-1725E-mail: [email protected]
Megan Mackin – Statewide Outreach CoordinatorPhone: 617-886-1728E-mail: [email protected]
DentaQuest Boston MassHealth Contacts
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Third Party Liability Claims
As of May 1st 2015 all TPL claims must be submitted electronically
MassHealth is ALWAYS the payor of the last resort (Except HSN)
All TPL claims MUST have a primary EOB attached or a termination letter to prevent a claim DENIAL
All dates of service and procedure codes from the primary EOB MUST MATCH the claim being submitted to MassHealth
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MassHealth Electronic Initiatives
MassHealth Requires • All Providers to be enrolled in Direct Deposit• To submit claims electronically
Eligibility Tools Available:• 24 Hour Provider Web Portal (www.masshealth-dental.net)• 24 Hour IVR Phone System (800-207-5019)
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Denture Coverage Restoration- Adults
Effective: May 15, 2015
Codes Covered: D5110-D5731 Dentures, Partials & All
Associated Codes
Benefit Change Notification
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Top Five CHC Claim Denials Service is not covered
Subscriber is not eligible for services under this plan
This procedure has been submitted after the timely filing limit
The patient was covered on the date(s) of service by another company which is the carrier
Encounter rates are payable only when submitted with the encounter code with corresponding fee and at least one valid dental procedure
Check Office Reference Manual for Covered Service
Check Member Eligibility on date of service
MassHealth allows 90 days from date of service to submit claims
Submit MassHealth Claim with Primary Insurance EOB
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D9450 must be submitted with a payable MassHealth Code
Health Safety Net (HSN)Denials
Do NOT mark “YES” for other insurance when submitting a claim to MassHealth or the claim will deny systematically looking for the Primary EOB
HSN is always secondary
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Ordering, Referring & Prescribing Provider Requirements
Ordering and Referring Requirements Background:
• ACA Section 6401(b)• States must require:
• All ordering or referring physicians and other professionals be enrolled under the State [Medicaid] Plan….as a participating provider; and
• The NPI of any ordering or referring physician or other professional…be specified on any claim for payment that is based on an order or referrals of the physician or other professional.
• These requirements were effective March 25, 2011. Final Rule (42 CFR 455.410(b) and 42 CFR 455.440) was published in the Federal Register on Feb. 2, 2011. Subregulatory guidance was given to states on December 23, 2011.
• MassHealth is currently on track to partially implement by September 1, 2015.
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Ordering and Referring Requirements Providers that may order, refer or prescribe services for MassHealth
members will need to enroll with MassHealth at least as Ordering, Referring, Prescribing (O/R/P) non-billing providers• Physicians * (including interns and residents +)• Dentists *• Podiatrist * • Optometrist *• Nurse Practitioner *• Certified Nurse Midwife *• Clinical Psychologist +
• State law (Chapter 118 of the Acts of 2012) will require that these provider types must apply to enroll with MassHealth for at least the purposes of O/R/P in order to obtain and maintain state licensure. This law will go into effect upon promulgation of MassHealth enrollment regulations, scheduled for [spring]/summer/fall of 2015.
+ The Supplemental Budget filed on February 27, 2015 adds the same requirement for these provider types
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Ordering and Referring Requirements • O/R/P providers will not be required to provide services to MassHealth
members
• MassHealth is finalizing a “streamlined” enrollment process for “O/R/P non-billing only” providers
• MassHealth is crafting an outreach strategy to providers currently not participating in MassHealth to inform them of this requirement
• We are on track to begin O/R/P enrollment in within the next few months and are coordinating with the boards of registration on the licensure requirements
• The state law also requires that providers must apply to enroll with MassHealth for at least the purposes of O/R/P to be included in private insurance provider networks so we will also be coordinating with the Division of Insurance on enforcement of that requirement
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Ordering and Referring Requirements
• Any service that requires a PCC referral
• Medications• Psychological
Testing• Therapy (PT, OT,
ST)• DME and
Oxygen/Respiratory Equipment
• Prosthetics and Orthotics
• Labs and Diagnostic Tests
• Eyeglasses• Hearing Aids• Personal Care• Home Health• Independent Nurse• Adult Foster Care• Adult Day Health
List of services that must be ordered, referred or prescribed:
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Ordering and Referring Requirements
• Psychologist (05)• Therapist (07)• Volume Purchaser (31)• Pharmacy (40)• DME (41)• Oxygen and Respiratory (42)• Prosthetic (43)• Hearing Instrument Dispenser (44),
hearing aid claims only• Diagnostic Testing Facility (45)• Certified Independent Lab (46)• Orthotic (47)
• Audiologist (50), hearing aid claims only
• Personal Care Attendant (58)• PCA Agency (59)• Home Health (60)• Independent Nurse (61)• Adult Foster Care and Group Adult
Foster Care (62)• Adult Day Health (63), except for
transportation claims• Group Practices (97), for
Psychological testing and Therapy services only
• Claims from these provider types for the services listed slide 5 will be subject to the O&R requirements starting with dates of service on or after 9/1/15:
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Ordering and Referring Requirements
• MassHealth is on track to start denying claims that don’t meet the Ordering and Referring requirements for dates of service on or after September 1, 2015.• The O/R/P provider’s NPI must be included on the claim• The O/R/P provider must be one of the provider types
identified• The O/R/P provider must be enrolled with MassHealth, at
least as a non-billing O/R/P provider• MassHealth is preparing guidance for billing providers, that
includes information about ordering and referring providers as well as other non-billing providers whose NPI may be included on MassHealth claims (e.g., to comply with HIPAA Version 5010).
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MassHealth Outreach
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Age One Dental Visits
The American Dental Association used to recommend that dentists start seeing children beginning at age 3. Those guidelines, however, have changed. The American Academy of Pediatric Dentistry (AAPD), the ADA, and the American Academy of Pediatrics all now recommend a dental visit for children by age one or the eruption of their 1st tooth.
To access MassHealth coverage information, please refer to the MassHealth Office Reference Manual located on the MassHealth web portal at www.masshealth-dental.net. A list of covered dental codes and service limitations for members under 21 is available in Exhibit A.
1. American Academy of Pediatric Dentistry, Get It Done in Year One, http://www.aapd.org/assets/2/7/GetItDoneInYearOne.pdf, July 2010.
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Procedure Code Description of Services Age Limits Teeth Prior Authorization
Required Benefit Limitation
D0145 Oral Evaluation Under 3 Years of Age 0-3 N/A No
Two of (D0120, D0145) per 1 Calendar year(s) Per Provider or Location.
D1120 Prophylaxis- Child 0-13 N/A No
Two of (D1110, D1120) per 1 Calendar year(s) Per patient. Includes minor scaling procedures.
D1206 Topical Fluoride Varnish 0-20 N/A No
One of (D1206, D1208) per 90 Day(s) Per Provider OR Location. Cannot be billed with D1208 on same date of service by the same provider or location.
D1208 Topical application of fluoride-Under 21 0-20 N/A No
One of (D1206, D1208) per 90 Day(s) Per Provider OR Location. Cannot be billed with D1206 on same date of service by the same provider or location.
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Office Reference Manual : Exhibit A : March 25, 2015
Fluoride Varnish in a Medical Setting
Children up to age 3 usually see a primary care provider more than eleven times for well-child care before their first visit to a dentist.
Yet early intervention is so important to the prevention of dental disease.
Primary care providers are in a unique position to identify existing problems, assess the risk of future problems, and provide guidance to parents.
Our goal is to increase the number of medical practices providing fluoride varnish services and promoting oral health when treating MassHealth Under 21 members.
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New Medical Providers and CHC’s
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A Sealant Program™ for Dentists-MassHealth Network
Claims Analysis DentaQuest will analyze claims data for a specific time period to
determine the number of members with sealant who visited that dentistMeasurements
We will measure the percentage of these members who received sealants on their first molars (ages 6 - 9) and second molars (ages 10 -14)
Provider education & training Participating dentists will be provided program information, resource
toolkit, patient report and set thresholds
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POSTER BROCHURE
Prevention Focus Program
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The Numbers Are In!
Sealant Program First Results - September 2014-February 2014
Members who were included on the list to providers: 76,724
Members who received a sealant after the mailing: 10,087 or 13%
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Some Helpful Hints & Resources
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Helpful Internet Links and Resources
Provider Web Portal – Check eligibility, submit authorizations & claimshttps://masshealth-dental.net
Vendor Web – Use this to check on payment statushttps://massfinance.state.ma.us/VendorWeb/vendor.asp
NPPES – Use to obtain, verify, and update NPI informationhttps://nppes.cms.hhs.gov/NPPES/Welcome.do
Regulations Updates – Sign up to get notified of any changes in the regulationsmailto:[email protected]
IVR/Call Center - (800)-207-5019 available 24 hours a day
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Questions & Answers
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