Presented by Jeffrey M Fike, DDS

Dental Updates

DENTAL CHECK

Keystone First is pleased to introduce Dental Check, a dental program that integrates the goals and values of providing high-quality and cost-effective preventive dental care for Keystone First members ages 0 to 20, while providing our dental providers with supplemental payments for partnering with us to improve clinical outcomes.

Goals• To provide our dental providers with a unique opportunity to improve clinical outcomes and

compensate them for their efforts.• To address health care disparities to ensure our members with cultural and

linguistic needs have access to the best possible dental care and services.

Dental Check program details:

• To reduce risks related to poor dental hygiene and associated risks for dental caries for Keystone First members ages 0 to 20:

• Provide members ages 0 to 20 with oral hygiene instructions (OHI) on the date of prophylaxis.

• Provide members ages 0 to 20 with a caries risk assessment (CAT) and corresponding documentation on the date of prophylaxis.

• Submit claims with CAT results using the appropriate risk stratification CDT procedure codes.

• Provide an additional prophylaxis and/fluoride treatment* visit for members identified as high-risk in the CAT.

DENTAL CHECK

A key component of the Dental Check program is to provide quality dental care to a culturally diverse membership. To be successful in meeting this goal, the full engagement of our provider network is crucial. We encourage you to take advantage of the free Cultural Competency Oral Health Provider continuing education

(CE) training opportunity offered at the following site: https://oralhealth.thinkculturalhealth.hhs. gov/

Training participants may earn up to 6 CE credits.

DENTAL CHECK

Join us in reducing risks related to poor dental hygiene andassociated risks for dental caries for Keystone First members ages 0 to 20

by providing these services:

• Give OHI on the date of prophylaxis.

• Complete the American Dental Association (ADA) CAT form (0 – 6 years of age or > 6 years of age)* on the date of prophylaxis.

• Submit CAT results using the appropriate risk stratification CDT procedure codes.

• Provide an additional prophylaxis and fluoride treatment** for members identified as high risk in the CAT.These additional services can be provided at a 90-day interval, after the date of the initial prophylaxis, without additional authorization from Keystone First. Reimbursement for this treatment will be in accordance with the terms of your participation agreement with Keystone First.

DENTAL CHECK

Code

Description

SupplementalPayment

Service Limitations

D1330

Oral hygiene instructions

$5.00

One per member per 180 days

D0601

Caries risk assessment with a finding of low risk

$10.00

One per member per 180 days

D0602

Caries risk assessment with a finding of moderate risk

$10.00

D0603

Caries risk assessment with a finding of high risk

$10.00

Effective for dates of service on or after June 15, 2015, Keystone First will make supplemental payments in accordance with the below fee schedule for oral hygiene instructions provided to and/or caries risk assessments completed for eligible Keystone First members:

*Please refer to the ADA CAT form for complete details and instructions. Do not submit the form. Please keep the completed form in the member’s dental file. For additional forms, please visit http://www.ada.org.**Current benefit guidelines and age limitations apply.

Benefit Limit Exception Form

Dental Benefit Limit Exception Request Form

Failure to legibly complete all fields and provide required documentation will result in this form being returned.

This form must be attached to a completed ADA dental claim form.

Please Print:Member Last Name: _________________________________ First Name: _________________________________Member KF ID#: _________________________________ Recipient Date of Birth: _______________________Provider Last Name: _________________________________ First Name: _________________________________Provider KF ID# _________________________________ NPI #: _____________________________________Provider Telephone Number: (Area Code): _______________ Phone: ____________________________________

Benefit Exception Request Type: □ Prospective □ Retrospective - Dates of Service:

Benefit Limit Criteria to be reviewed (Check all that apply): □ Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the recipient. □ Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the serious deterioration of the health of the recipient. □ Granting the exception is a cost-effective alternative for the Plan. □ Granting the exception is necessary in order to comply with Federal law.

Benefit Limit Exception Request for Periodontal Services Only Patient is pregnant, has diabetes or has coronary artery disease and meets clinical dental criteria for periodontal services included in the Plan’s benefit program.

This request must include documentation from the patient’s primary care or specialty care physician supporting the need for the service, including but not limited to chart documentation, diagnostic study results, radiographs (if applicable), medical and dental history.

Explain below why the patient meets the criteria for a benefit limit exception. The explanation should be in narrative form and include a comprehensive justification (attach additional pages as necessary). ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ A BLE requested before the dental service begins, will receive an answer, or a request for additional information to be provided, within 21 business days of receipt of the request. When additional information is required and received, the exception request will be approved or denied within 21 business days after receipt of the information. BLE retrospective requests must be submitted no later than 60 days from the date the claim was rejected and will be answered within 30 days. Retrospective exception requests made after 60 days from the claim rejection date will be denied. I attest that the information provided and statements made herein are true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact may subject me to civil or criminal liability. Provider Signature:________________________________________________________ Date: _____________________ Mail to: Request for Benefit Limit Exception, Keystone First, PO Box 2083, Milwaukee, WI 53201

FQHC OPPORTUNITIES

The role of the FQHC is crucial I the delivery care model for our multiple lines of business. Partnering with AmeriHealth Caritas will allow the FQHC a structured approach to improving dental health allowing for many opportunities for the facility to positively impact health and revenue.

• Maximize your opportunity for dual encounters• Close your care gaps• Collaboration

LET US KNOW PROGRAM

AmeriHealth Caritas Pennsylvania, AmeriHealth Caritas Northeast and Keystone First are eager to partner with the dental provider community in the management of our members.

We are here to help you engage members in their dental care, and to that end we are introducing the “Dental Let Us Know” program. We have many support teams and tools available to assist in the identification, outreach and education of our members, as well as clinical resources for providers in their care management.

LET US KNOW PROGRAM

How can you let us know about any issues or barriers to dental care our members may experience?

Utilize the new Member Intervention Request FormFax this form to 1-717-651-1673 or 267-198-5770 to request interventions for: • Inappropriate use of the ER for dental issues.• Inappropriate and/or disruptive behavior.• Non-compliance with dental office policies/procedures.• Limited or no knowledge of dental benefits.• Not showing up for appointments or follow up care.• Other issues.

The Dental department will work with members for issue resolution. The Dental Let Us Know program will work in conjunction with our other departments, which may be accessed through the following phone numbers:

LET US KNOW PROGRAM

AmeriHealth Caritas Pennsylvania

Integrated Healthcare Management 1-877-693-8271, option 2

Special Needs Unit 1-800-684-5503

Bright Start® (maternity program) 1-877-364-6797

AmeriHealth Caritas Northeast

Integrated Healthcare Management 1-888-208-5966

Special Needs Unit 1-888-498-0766

Bright Start® (maternity program) 1-888-208-9528

Keystone First

Complex Case Management 1-800-573-4100

Bright Start® (maternity program) 1-800-521-6867

LET US KNOW PROGRAM

Member Intervention Request FormDate: _____________

Member Information

Dental Provider Information

Please check the appropriate intervention(s): Inappropriate use of emergency room for dental related issues Not showing up for appointments or follow-up care Limited or no knowledge of plan benefits Inappropriate and/or disruptive behavior Dental patient non-compliant with office policies/procedures Refer to Integrated Care Management Other:

Additional information or comments:

______________________________________

______________________________________

______________________________________

Please fax this completed form to 1-717-651-1673 .

Follow-up performed: __________________________

Comments:___________________________________________________

Please address your questions regarding this communication to the AmeriHealth Caritas Pennsylvania and AmeriHealth

Caritas Northeast Dental Program Manager at 1-717-651-3599.

Member name Date of birthMember ID number Phone number

Parent or guardian name (if applicable)

Dentist’s name Group name

NPI # Group TIN

Phone number Fax number

Office contact name

AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast, in partnership with the Pennsylvania Head Start Association, are pleased to invite you to attend a free continuing education program.*

Cavity Free Kids in Your Community August 7, 2015, 10:00 a.m. – 4:30 p.m. Hilton Scranton & Conference Center 100 Adams Avenue, Scranton, PA 18503 Who should attend: Dentists, hygienists, expanded-function dental assistants, outreach coordinators and office managers.

R.S.V.P. to: Jenn Landis at jlandis@amerihealthcaritaspa.com or 1-717-651-3590 by August 4, 2015. Presenters: Susan Granquist, D.M.D. Lori Wood, R.D.H., P.H.D.H.P., C.D.H.C. Christi Binder, B.S.D.H., P.H.D.H.P. Harris Daniels, M.A.T. Amy Requa, M.S.N., C.R.N.P.

*This program has been approved by the Academy for Dental Hygiene Studies. Upon completion, participating dentists and hygienists will be eligible to earn 6 free continuing education credits.

CAVITY FREE KIDS IN YOUR COMMUNITY

Course agenda

Course learning objectives. Course participants will be able to: • Describe current science and knowledge about effective

oral health practices for pregnant women, children from

birth to kindergarten, adolescents, and families.

• Demonstrate educational and learning activities to improve

the delivery of oral health promotion and disease

prevention concepts to parents, children and adolescents in

office settings.• Identify strategies to integrate oral health messages and

techniques to engage parents, children and adolescents in non-traditional settings in the community.

9:30 a.m. – 10:00 a.m. Sign ln

• Complete the pre-test. 10:00 a.m. – 10:20 a.m. Welcome and Introductions

• What is Cavity Free Kids?

• What is the big picture? Review course objectives, purpose and expectations.

• Dental and medical providers, health educators, and community outreach: professionals

working together. 10:20 a.m. – 12:00 p.m. A Lifetime of Oral

Health Presentation • New science-based information: getting on the same page.

• Cavity Free Kids: “easy to do” demonstrations and activities.

• Using Cavity Free Kids as a practice builder. 12:00 p.m. – 12:30 p.m. Lunch Break

CAVITY FREE KIDS IN YOUR COMMUNITY

12:30 p.m. – 2:45 p.m. A Lifetime of Oral Health

Presentation (continued) • Getting to know the Cavity Free Kids curriculum.

• Engaging young children in your waiting rooms.

• Motivational interviewing — using teachable moments.

• Engaging families with instructional aids.

• Increasing referrals in your practice with Cavity Free Kids.

2:45 p.m. – 3:00 p.m. Break: Get free resources! 3:00 p.m. – 3:45 p.m. Informing and Promoting

Oral Health in Adolescents • What motivates behavior changes in adolescents?

• Ideas for educating adolescents. 3:45 p.m. – 4:15 p.m. Making Cavity Free Kids

Come Alive • Small group activity.

4:15 p.m. – 4:30 p.m. Wrap up • Complete the post-test and turn it in with continuing education

paperwork.

• Training course evaluation.

• Receive continuing education certificate.

Contact Information

Jeffrey M Fike, DDSDental Director, AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast8040 Carlson Road, Suite 500Harrisburg, PA 17112717-943-1813jfike@amerihealthcaritas.com