A New Day For Oral Health In Virginia Tooth Talk December 12, 2007

2 Smiles For Children Program An Overview

3 Who’s Eligible and How to Apply?  To participate in Smiles For Children (SFC), recipients must first be eligible for Medicaid, FAMIS or FAMIS Plus.  Once eligible, recipients are automatically enrolled in the SFC program and receive a Member Handbook.  Recipients do not receive a SFC ID card. Recipients may use:  Commonwealth of Virginia (blue and white) plastic identification  MCO identification card  For questions regarding Medicaid eligibility, recipients should:  Visit their local Department of Social Services  For questions regarding FAMIS or FAMIS Plus eligibility, recipients should:  Go online and visit: orwww.famis.org  Call FAMIS ( )

4 Enrollee Eligibility  Doral uses the 12-digit Medicaid ID number as the enrollee ID Number.  Eligibility may be confirmed using:  Doral website  By calling  DMAS MediCall voice response system at or listen to the entire message  If DMAS Medicall voice response system is used, providers are cautioned to listen to the entire message. Members may be in a waiver program, such as the Family Planning Waiver, and may not be eligible for dental benefits.

5 Interactive Phone System AVAILABLE 24 HOURS A DAY!  By dialing and choosing option 1 providers can access:  Patient Eligibility  Limited Claims History  Fax Back Confirmation of eIVR call  Spanish Call Handling  Patients eligibility can be verified on the eIVR along with limited claim history (codes: D0120, D0150, D0210, D0272, D0274, D0330, D1110, D1120, D1201, D1203, D1204, D1205, D1351, D5110, D5120, D5130 and D5140)  Confirmation fax of the eIVR available to providers who use the system  Option to choose Spanish or English

6 Enrollee Eligibility – FAMIS MOMS  FAMIS MOMS receive comprehensive health care benefits during pregnancy and for two months following the end of pregnancy-this includes SFC dental benefits if under twenty one years of age. Detailed information is available at  Providers are encouraged to contact Doral to verify eligibility prior to rendering services.

7 Benefits For Enrollees Under Age 21  SFC provides comprehensive dental benefits for enrollees under the age of 21: –Diagnostic –Preventive –Restorative –Endodontics –Periodontics –Prosthodontics Removable –Prosthodontics Fixed –Oral Surgery –Orthodontics –Adjunctive General  A full explanation of benefits can be found in the Office Reference Manual, Exhibit A.

8 Benefits For Enrollees Age 21 and Older  Coverage for adults, age 21 or older, is limited to medically necessary oral surgery and associated diagnostic services.  Diagnostic services include the oral examination and selected radiographs needed to assess the oral health, diagnose oral pathology, and develop an adequate treatment plan.  Extractions for adults must be medically necessary and be complicating the patient’s general health as documented by the dentist or medical provider:  Severe periodontal infection which causes acute pain, loss of appetite or weight due to pain or infection  Exacerbates a medical condition/medical management such as diabetes, heart valve condition

9 Benefits For Enrollees Age 21 and Older Prepayment Review  Services for adults require Prepayment Review:  Services requiring prepayment review, require that proper documentation be submitted with the claim following treatment in order for the claim to be considered for reimbursement.  For all services that require Prepayment Review, Providers have the option of requesting prior authorization:  Services requiring prior authorization/pre- determination require that documentation regarding the medical necessity of the proposed treatment be submitted and authorization from Doral be obtained before the services are rendered.  A full explanation of benefits can be found in the Office Reference Manual, Exhibit B.  Oral surgery procedures not listed in Exhibit B may be covered under the member’s medical benefits through the Medicaid, FAMIS, or FAMIS Plus fee-for-service or managed care organization (MCO) program.

10 Office Reference Manual  Policies and procedures  Instructions for claims filing  Benefits and limitations  Instructions regarding services that require prior authorization  Orthodontia criteria  Outreach services  American Academy of Pediatric Dentistry (AAPD) dental care guidelines  Important phone numbers and addresses The Office Reference Manual (ORM) is available on line: Go to Click on “Providers.” After logging in, “View Documents” or Download a copy from the DMAS website at

11 Provider Web Portal (PWP)  Meets accessibility standards put forth by the ADA (Americans with Disabilities).  Users can use any browser – no longer limited to “Internet Explorer.”  New improved look for ease of use.  Easy to read menu.  form for streamlined communication.  Payment release dates so Providers can easily track payment dates.  Location information displayed for the office staff to check accuracy and update the information via a contact form.  Claims and authorization entry still available with accurate reporting and tracking information.

12 Enrollee Outreach Initiatives

13 Broken Appointments  Broken appointments:  A major concern for DMAS, VDA, ODDS, and Doral  Recognized as expensive for dentists  Lead to dentists unwillingness to participate in the program  In December 2005, Doral implemented the Broken Appointment Tracking Initiative in order to collect data to better track, trend, and understand the issue  Doral uses the information to:  Educate families regarding the importance of appointments and compliance with treatment plans

14 Broken Appointment Initiative  Broken Appointment Tracking Log Outcomes  Over 10,000 broken appointments from SFC participating dentists have been received since Fall  Enhancements to the Broken Appointment Tracking Form  Missed appointment - a missed appointment where the member or member representative did not call to cancel  Late Notice Cancellation (LNC) - a missed appointment with a cancellation less than 24 hours prior to the appointment time  Reason codes - 1) forgot about appointment., 2) conflict with schedule, 3) transportation 4) illness, 5) other. Next Steps:  Broken Appointment Best Practices Questionnaire  Broken Appointment Focused Survey  SFC Broken Appointment Pilot Program

15 SFC Transportation Complaint Form  Analyses of data related to broken appointments indicate problems with transportation as one reason for broken appointments.  Providers are encouraged to report problems with transportation to DMAS. The SFC Transportation Complaint Form can now be used to report problems.

16 Interpreter Services- Pending Implementation  Title XIX of the Social Security Act requires Medicaid providers to provide non-discriminatory services to its clients including those with limited English proficiency.  In order to help providers with this requirement, DMAS has implemented a provision for reimbursement of interpreter services under the SFC program when there is a need and it relates to the treatment.  In order for the SFC dentist to be reimbursed for interpreter services performed at the dental office, the provider must submit documentation (invoice) of the services provided by and paid to a professional interpreter. The following elements must included in the documentation:  Date(s) of Service  Patient name and ID number  Copy of the invoice showing the name, address and telephone number of the professional interpreter service, the type and length of service, and the amount paid  Mail the SFC Professional Interpreter Service Invoice Form along with the above documentation to: Doral Dental ATTN: Lori Howley N. Corporate Parkway Mequon, WI  An interpreter services resource listing will be located on the DMAS website, A copy of the resource listing will also be available upon request.

17 How to Locate a Provider

18 Provider Directory Contents:  Provider name  Practice name  Office address(es)  Telephone number(s)  Provider specialty  Panel status  Office hours  Languages spoken  Any other panel limitations Directory may be downloaded from the DMAS website at: or from the Doral website at:

19  Open Microsoft Internet Explorer and access  Click on the “Find A Provider” button to continue. Doral Dental USA Website

20 Find A Provider  You must provide at least a zip code to perform a search.  Select VA-Smiles For Children from the drop down menu.  Click “Find Providers”

21 Find A Provider Search Results  Search options allow you to narrow a search by:  Provider Specialty  Languages Spoken  Mileage Radius  Hospital Affiliation

22 Contact Information Doral Smiles For Children Staff:  Cheryl Harris: Project Director Direct Line: (804) Fax: (804)  Anna Perez: Provider Relations Representative Direct Line: (804) Fax: (804)  Kristen Gilliam: Outreach Coordinator Direct Line: (804) Fax: (804) DMAS Smiles For Children Staff:  Sandra Brown, MSW: Dental Program Manager Direct Line: (804) Fax: (804)  Dr. Marjorie Chema, DDS: Dental Consultant Direct Line: (804) Fax: (804)  Lisa Bilik: Dental Contract Monitor Direct Line: (804) Fax: (804)

Thank You!