1 Spring 2012 PROVIDER TRAINING Spring 2012 PROVIDER TRAINING April/May 2012

2 2 WELCOME & INTRODUCTIONS

3 3 Training Objectives  Credentialing and Recredentialing – required documentation, process, expectations  Authorization Submissions  Top Claim Denial codes and how to avoid these issues  IVR self service functions – how to access answers to eligibility and claims faster  Claims/authorizations using the Portal with attachments features  Sealant Program  Direct Deposit

4 4 CREDENTIALING AND RECREDENTIAING PROCEDURES

5 5  All new providers enrolling into Medicaid/Smiles For Children program are required to complete several documents in order for the application to begin the process of credentialing  The documents include the Smiles For Children Application, Participation Agreement, DentaQuest Contract, w-9, Copy of Dental License and Copy of Liability Policy  Read the application and complete all required fields.  Those applications received with missing information or improperly filled out the provider will get three opportunities to send the correct information.  Providers needing to make changes to his/her panel are required to submit the request on the Provider change form and letter of request (including a w-9) i.e. change of tax id, name change  All providers adding a brand new location are required to submit a provider change form w-9 and contract for the new location  The entire application and all required documents are available on the Provider Web Portal under Related Documents and can be downloaded including Provider change form CREDENTIALING DOCMENTATION

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7 7 RECREDENTIALING POLICIES AND PROCEDURES  Recredentialing occurs every three years for Smiles For Children providers  A letter along with a Pre-Populated Recredentialing Application will be mailed to providers requiring recredentialing.  The Recredentialing applications must be completed and mailed back at least four weeks prior to term date of the application  If the recredentialing application is not completed on time, the provider will be terminated and will have to reapply as a new provider  Not completing the recredentialing application will result in claims not paying for Non-Par status

8 8 TOP DENIALS WITH AUTHORIZATIONS AND CLAIMS

9 9 AUTHORIZATION DENIALS AND RESOLUTIONS  UM receiving OR authorization claim requests with D9500 This is not the correct code to be submitted for OR authorization. D9999 should be submitted by the provider for OR cases. The authorization request should include the explanation for need of medical necessity and clinical criteria to treat in the OR. A blanket statement is not acceptable. Must include tentative Date of Service and Place of Service  Submission received for OR cases not a medical reason to allow services in an hospital setting Must submit request with OR Criteria. See Section of the ORM

10  UM receiving Prior Authorization requests with inadequate diagnostic quality x-rays X-rays submitted with non-diagnostic quality x-rays will be denied Must submit prior authorization requests with diagnostic quality x-rays and narrative explanation of the need of medical necessity when appropriate When necessary submit photos to support the medical need (especially if this can not be determined solely from the x-ray)

11  Authorization release requests are being received without an ADA claim form or a determination letter Must submit on an ADA claim form note in box 35 request to release auth and include authorization number. Due to our automated system the request must be on the ADA claim form. It is acceptable to submit the original authorization claim noting in box 35 the auth # and request to release authorization.

12  Submissions for EPSDT are not being checked on box 1 of the ADA claim form Be sure and check EPSDT in box 1 of the ADA claim form EPSDT requires review that EPSDT be indicated on the prior authorization request Include need of medical necessity Must include the actual treatment ADA code

13 CLAIM DENIALS AND WAYS TO AVOID  Claims not being submitted with periapical x-ray Codes that require periapical x-rays for payment must be of diagnostic quality (documentation required for pre-payment review)  Claims are being submitted with no panorex or Full mouth series of x- rays Codes that require panorex or FMX x-rays for payment must be of diagnostic quality (documentation required for pre-payment review)  Receiving numerous claims as duplicated previously paid Prior to resubmitting the claim review the status in the Provider Web Portal

14  Claims denying for narrative describing treatment and/or narrative regarding medical necessity Codes that require narrative of medical necessity for payment must be submitted (documentation required for pre-payment review)  Receiving claims with non-diagnostic or poor quality x-rays. The Dental Director can not make a determination with poor quality or non-diagnostic x- rays. Must submit with diagnostic quality x-rays to be reviewed for payment  X-rays are non supportive for code submitted Submit code that reflects the code appropriately. Include narrative supporting the code for more complex treatment  Orthodontic claims denying for member terminated Claim must be submitted with last date member was eligible for services with D8999 including remaining balance. In remarks field include banding date and member in active treatment and authorization number.

15  Orthodontic Quarterly (8670) submission not being sent with an actual date of service 3Providers must submit claims for 3 quarterly payments (D8670) and the claims must be submitted with an actual date of service at least 91 days apart from the last actual date of service.  Information sent shows no significant signs of infection or any other reason for tooth removal Submit appropriate information to show your findings (i.e. x-rays, photos, treatment notes)  Claims/x-rays and narrative not showing the necessary evidence of bone loss to support periodontal scaling and root planing Submit with perio charting, treatment notes or photos if necessary to support the codes submitted  Claims information for Nitrous Oxide are not indicating medically necessary Must submit with adequate need for using Nitrous Oxide  Claim received notes member covered by another carrier but the EOB not attached to claim Resubmit claim with copy of the primary carrier’s EOB for payment consideration

16 CHANGES TO OFFICE REFERENCE MANUAL  EFFECTIVE MAY 15, 2012  Revised EXHIBIT A, D0210 – INTRAORAL-COMPLETE SERIES (including bitewings): One of (D0210, D0330) per 60 Month (s) Per Provider and Location for children age six and older. Reimbursement per 36 months is no longer permissible.  Revised EXHIBIT A AND EXHIBIT B, D PANORAMIC FILM: One of (D0330, D0210) per 60 month (s) Per Provider and Location for members age six and older. Reimbursement per 36 months is no longer permissible.  If a member requires a panoramic film or intraoral complete series, including bitewings more frequently than once every 60 months, the claim must be supported with a narrative of medical necessity.

17 IVR SELF SERVICE FUNCTIONS

18  Ability to verify benefits and eligibility and obtain a procedure history  Ability to have information faxed back to you  Once member information (such as membership number or date of birth) is entered, you will be able to jump between menus without re- entering that information  Caller dials Provider Services incoming phone number ( )  Caller is prompted for English vs Spanish  Caller enters NPI  Caller enters last 4 digits of TIN  IVR validates caller: If provider is found – continues to enter member information If provider is not found – continues to limited options

19  Caller enters member information Member ID (12 digit number only) DOB (First 4 characters of last name if the ID is alpha numeric)  IVR validates member information: If member is found – continues to main menu If member is not found – prompted to re-enter information  Main Menu (when both provider and member are found in system) Eligibility Benefit Sub Menu Benefit Summary Benefit Detail Procedure History Claims Authorizations Web Support All other inquiries

20  “Limited Menu” (for providers that are not in system) Eligibility Benefit Summary Benefit Detail All other inquiries

21 SEALANT PROGRAM

22 WHAT IS PREVENTISTRY? DentaQuest’s Preventistry approach thoughtfully integrates benefits, programs and policies to promote prevention-focused oral healthcare in order to achieve our vision of a world free of dental disease. Our Preventistry benefit program empowers dentists and engages members to take a more active role in improving oral health by providing coverage and practical information about important preventive services.

23 Dental caries is the most common chronic childhood disease, five times more common than asthma and almost 100% preventable  Dental caries (decay) is a bacterial infection that can spread from tooth to tooth  Decay most often occurs (about 90%) in the deep grooves on the biting surfaces of molars  Preventing decay not only improves oral health but also reduces the cost of care WHY FOCUS ON PREVENTIVE CARE?

24 HOW CAN CARIES BE PREVENTED* The ADA recommends the use of sealants to reduce the occurrence of caries Sealants are most effective when applied early Caries reduction in children with sealants ranges from 86% at one year to 79% at two years Private dental insurance and Medicaid databases show the use of sealants on 1 st and 2 nd molars is associated with reductions in the subsequent provision of restorative services *Information from the ADA Sealant Recommendations

25 RECOMMENDED SOLUTION Introduce the DentaQuest “Preventistry SM Sealant Program”  Encourage members to have sealants place on 1 st molars of children ages 6 and 7  Encourage members to have sealants place on 2 nd molars of children ages 12 and 13  Provide the members with the tools they need to be successful

26 Provider Web Portal Key 1.Portal Menus – The Administration, Claims/Pre-Authorizations, Patient, and Tools menus are displayed along the left side of the Client portal. 2.Welcome – This section contains the DentaQuest welcome message. 3.Health news – This section contains information and news articles of interest. You can access the news articles by clicking on their respective links. 4.My Health Tools/Resources – This section contains links to various health resources. 5.Contact – This section contains DentaQuest’s contact information. 6.Message Center – This section contains secure messages sent to you from DentaQuest. NOTE: The Message Center only appears on your Home page if there are messages in your Inbox. 7.FAQ – This link opens the View FAQ page where you can view frequently asked questions. 8.Event Calendar – This link opens the Event Calendar. 9.Related Documents – This link opens the Document List page. Examples- ORM, Web Portal Training Guide.

Provider Home Page See Key on Next Slide

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29 Claim/Prior Authorization Menu Status  Enter at least one search Criteria:  Member 12 digit Subscriber id number  Member first name  Member last name  Member’s date of birth  Select the dentist from the Servicing Treating Dentist drop-down list  Claim/pre- authorization number field

30 Find the claim/pre-authorization status you want to view. In the Results section on the Claim/Pre-Authorization Status List page, click the Claim/Pre-Authorization Number link for the claim/pre- authorization status you wish to view. The Claim/Pre- Authorization Status Detail page appears.

31 Member Information – contains information about the patient Servicing Dentist Information – contains information about the serving dentist Claim/Pre-Authorization Information – contains information about the claim/pre-authorization COB Information-contain information about Coordination of Benefits, if available Service Line Information-contains information for each procedure code submitted Processing Policies- contains information on any applicable processing policies for the claim/pre- authorization File Attachments-lists any files that have been attached to the claim/pre-authorization

32 Dental Claim Entry  Basic Information – enter the basic office information for the claim in this section.  Member Eligibility – enter member information in this section  Service Lines – enter the services related to the claim in this section File Attachments – attach any files you need for the claim in this section.  Optional information – you can select the COB option, EPSDT option, Emergency option, enter optional accident information, and enter your NEA Attachment ID (if you are using the NEA to submit an attachment with this claim) in this section. A COB section only appears on the page if you select that option.

33  Select the type of report you are attaching from the Report Type drop-down list  Accepted File Types (attachments) Word document (.doc) PowerPoint files (.ppt) Excel files (.xls) Comma-separated values files (.csv) Text file (.txt and.rtf) Images (.gif,.jpg,.jpeg,.png, and.bmp) Zipped files (.zip) HTML files (.htm and.html) PDF files (.pdf) XML files Orthocad files (.3dm) Add File to claim/Pre-Authorization

34 Dental Claim Confirmation Report  Allows you to open view and all claims/auths for the day only  The report must be run at the COB daily (you can save it or print it)  Leave the type blank to view all the claims/auth or narrow your search using the drop down selection of your choice

35 GO GREEN WITH DIRECT DEPOSIT

36 WHY ENROLL IN DIRECT DEPOSIT?  Safer than checks, and helps eliminate forged, counterfeit, and altered checks.  Eliminates the risk of paper checks being lost or stolen in the mail.  Allows faster receipt of reimbursement.  Allows faster access to funds; many banks credit direct deposits faster than paper checks.  Payments are easy and convenient.  Valuable time savings for staff and avoidance of hassle associated with going to the bank to deposit your check.  Reduces the amount of paper in your office.

37 HOW TO ENROLL IN DIRECT DEPOSIT  To enroll providers must:  Complete, sign and return the authorization form  Include a voided check with the returned authorization form  Return your enrollment form:  Via Fax: or  Via Mail: North Corporate Parkway Mequon, WI ATTN: PEC Department  Allow up to six weeks for your Direct Deposit process to be implemented  You will receive a bank note one check cycle prior to your first Direct Deposit payment  Providers participating in Direct Deposit will no longer receive paper remittance statements. Access your remittance statements on line

38 DentaQuest Provider Relations Team Waradah K. Eargle Providers Relation Representative Toll-Free: Fax: Bridget Hengle Provider Relations Representative Toll-Free: Fax:

39 Accomack Albemarle Alleghany Amherst Appomattox Arlington Augusta Bath Bedford Bland Botetourt Brunswick Buchanan Buckingham Campbell Carroll Charlotte Chesterfield Craig Culpeper Dickenson Dinwiddie Fairfax Fauquier Floyd Fluvanna Franklin Frederick Giles Goochland Grayson Greene Halifax Henry Highland Wight King William Lancaster Lee Loudoun Louisa Lunenburg Mathews Mecklenburg Montgomery Nelson New Kent Northampton Northumberland Nottoway Page Patrick Pittsylvania Prince Pulaski Rockbridge Rockingham Scott Shenandoah Smyth Southampton Spotsylvania Stafford Surry Tazewell Warren Washington Westmoreland Wise Wythe Hampton Newport Virginia Beach Amelia Caroline City Clarke Cumberland Gloucester Greensville Hanover Henrico Isle of James City King and Queen George Madison Suffolk Orange Powhatan Edward William Rappahannock Richmond Roanoke Russell Sussex York Chesapeake Charles Essex King Middlesex Prince News George RegionRep NameAssigned Counties CentralBridget Hengle Green Counties Amelia, Brunswick, Buckingham, Charles City, Charlotte, Chesterfield, Cumberland, Dinwiddie, Goochland, Greensville, Halifax, Hanover, Henrico, Lunenburg, Mecklenburg, New Kent, Nottoway, Powhatan, Prince Edward, Prince George, Richmond, Surry, Sussex EasternBridget Hengle Red Counties Accomack, Chesapeake, Essex, Gloucester, Hampton, Isle of Wight, James City, King and Queen, King William, Lancaster, Mathews, Middlesex, Newport News, Northampton, Northumberland, Southampton, Suffolk, Virginia Beach, Westmoreland, York NorthernWaradah Eargle Pink Counties Arlington, Fairfax, Loudoun, Prince William NorthwestWaradah Eargle Purple Counties Albemarle, Augusta, Bath, Caroline, Clarke, Culpeper, Fauquier, Fluvanna, Frederick, Greene, Highland, King George, Louisa, Madison, Nelson, Orange, Page, Rappahannock, Rockbridge, Rockingham, Shenandoah, Spotsylvania, Stafford, Warren SouthwestBridget Hengle Blue Counties Alleghany, Amherst, Appomattox, Bedford, Bland, Botetourt, Buchanan, Campbell, Carroll, Craig, Danville, Dickenson, Floyd, Franklin, Giles, Grayson, Henry, Lee, Montgomery, Patrick, Pittsylvania, Pulaski, Roanoke, Russell, Scott, Smyth, Tazewell, Washington, Wise, Wythe 2012 VA Provider Relations Representative County Assignments

40 DMAS Smiles For Children Staff  Daniel Plain: Dental Program Manager Direct Line: (804) Fax: (804)  Lisa Bilik: Dental Contract Monitor Direct Line: (804) Fax: (804)  Dr. Marjorie Chema: Dental Consultant Direct Line: (804) Fax: (804)

41 THANK YOU FOR PROVIDING DENTAL CARE TO THE UNDERSERVED SMILES FOR CHILDREN MEMBERS IN YOUR COMMUNITY. WE GREATLY APPRECIATE YOUR DEDICATION!