Dental Seminar 2010

343 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
343
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
11
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Have them look at their Agenda page – and the back of the page for contact information.
  • We’re now going to spend some time talking about the DMA website in general and also show you the Dental website so you can get program specific information.
  • Check website before each seminar, read each initiative so we summarize what we cover today. It is being updated DAILY!!!!! 8/28/09: Enrollment Fees for Providers Paperless Commerce (including) Electronic Payments Medicaid Uniform Screening Tool for PASARR Program Reductions/Service Limitations Recipient Medicaid Identification Cards NCECS Recipient Eligibility Verification Tool – Sept 2009 Bulletin
  • Check website before each seminar, read each initiative so we summarize what we cover today. It is being updated DAILY!!!!! 8/28/09: Enrollment Fees for Providers Paperless Commerce (including) Electronic Payments Medicaid Uniform Screening Tool for PASARR Program Reductions/Service Limitations Recipient Medicaid Identification Cards NCECS Recipient Eligibility Verification Tool – Sept 2009 Bulletin
  • This may change as exceptions are identified – so review often!!!! Exceptions LIST There will still be EOBs that require medical records or attachments – you will initially need to submit them on paper if not on this list. You will need an ICN from the denial to resubmit the claim on paper. Follow the instructions for the specific EOB received Remember to review this – Definitely before sending any paper claims ----- AGAIN follow the instructions on the EOB of the electronic denial if you are submitting a paper claim for claims not on this list!!!!!!!
  • New look/layout to MID card ANNUAL No longer serves as proof of eligibility Must utilize one of the above methods to verify eligibility
  • Summarize each method, will review in detail in a moment …
  • Screen shot of recipient eligibility inquiry 4 options to search with available criteria CURRENT MONTH ELIGIBILITY
  • When submitting electronic adjustments, you have two choices. Void (explain) and Replacement (explain).
  • Read these 2 statements out loud because they’re new statements in the manual.
  • To be approved for D4341 (4 or more teeth – per quadrant) – there must be at least 4 teeth in the quadrant that have pockets depths of 4mm or greater. To be approved for D4342 (1 -3 teeth – per quadrant) – there must be 1-3 teeth in the quadrant that have pocket depths of 4mm or greater.
  • This slide shows an example of the top half of a properly completed PA request
  • Our next section is on Denial Notices
  • If a request for prior approval is denied because- (read each bullet point)
  • Here’s what the recipient letter looks like. The provider letter looks very similar.
  • This type of notification is not really a denial – it’s a Notice of Additional Information which means the PA dept. can’t go any further with their decision until they get additional information. A letter is sent to the provider and the recipient informing them as such. The provider should return the requested information or request an extension within 15 business days of the date of the notice. If the requested information or request for an extension is not received within the 15 business days of the date of the notice, the request will be denied on day 16.
  • This is what the letter to the provider looks like – the recipient also receives a notification letter.
  • c. 2 (the original and a copy for the EDS files)
  • c. delivery date
  • b. 25 (area of the oral cavity) is the preferred answer However, NC Medicaid does still accept the quadrant or arch indicator in field 27 (tooth number or letter) as stated on page 38 in the dental manual.
  • c. 1223G0001X (taxonomy code)
  • TRUE
  • TRUE
  • TRUE
  • TRUE
  • FALSE D1510 requires quadrant indicators UR, UL, LL, LR D1515 requires arch indicators UP, LO
  • TRUE
  • We’ll wrap up this seminar by providing you with contact information at DMA and EDS.
  • Addresses to send in your PA requests, claims, refunds and paper adjustments – also on the back of your agenda.
  • To get a live human being out to your office for a face to face visit, call the number you see on that agenda page.
  • And here is contact information over the phone for both the AVRS and a human.
  • Contacting DMA about recipient eligibility or about dental program coverage policies are also printed on the back.
  • Dental Seminar 2010

    1. 1. Dental Seminar 2010 Welcome!
    2. 2. Introduction <ul><ul><li>DMA Website </li></ul></ul><ul><ul><li>Medicaid Updates </li></ul></ul><ul><ul><li>Properly Completing Prior Approval Requests </li></ul></ul><ul><ul><li>Denial Notices </li></ul></ul><ul><ul><li>Test Your Dental Knowledge </li></ul></ul><ul><ul><li>Top Five Claim Denials </li></ul></ul><ul><ul><li>Contacting Medicaid </li></ul></ul>
    3. 3. DMA Website
    4. 4. DMA Website
    5. 5. Dental Seminar 2007 DMA’s Website
    6. 6. Drop Down Box
    7. 9. Dental Fee Schedule
    8. 10. Division of Medical Assistance NC Medicaid Dental Program <ul><li>http://www.ncdhhs.gov/dma/services/dental.htm </li></ul><ul><li>Mark W. Casey, DDS, MPH </li></ul><ul><li>Dental Director </li></ul><ul><li>[email_address] </li></ul><ul><li>919-855-4280 </li></ul>
    9. 11. Medicaid Updates
    10. 12. Budget Initiatives
    11. 13. Provider Enrollment <ul><li>CSC (Computer Sciences Corporation) assumed responsibilities from DMA in April 2009 </li></ul><ul><li>Contact Information: </li></ul><ul><ul><li>Phone: 866-844-1113 </li></ul></ul><ul><ul><li>Fax: 866-844-1382 </li></ul></ul><ul><ul><li>Website: http://www.nctracks.nc.gov </li></ul></ul>
    12. 14. Enrollment Verification <ul><li>Information was mailed to providers in December of 2009 </li></ul><ul><li>Medicaid providers who have not been credentialed in the last 18 months </li></ul><ul><li>Information should have been verified and returned to CSC within 30 days </li></ul>
    13. 15. Budget Initiatives
    14. 16. Electronic Claims Submission <ul><li>Mandatory as of October 2, 2009 </li></ul><ul><li>Cost saving measure </li></ul><ul><li>Refer to the October 2009 bulletin </li></ul><ul><li>ECS Agreement </li></ul>
    15. 17. Electronic Claims Exceptions <ul><li>Any dental claim billed with one of the following ADA procedure codes: </li></ul><ul><ul><li>D0340 </li></ul></ul><ul><ul><li>D0470 </li></ul></ul><ul><ul><li>D8680 </li></ul></ul><ul><li>Unclassified and unlisted procedures: </li></ul><ul><ul><li>D7999 </li></ul></ul>http://www.ncdhhs.gov/dma/provider/ECSExceptions.htm
    16. 18. Electronic Claim Exceptions <ul><li>Undelivered dentures </li></ul><ul><li>Dental claims for special consideration tooth number reviews </li></ul><ul><li>Dental assistant surgeon claims with records </li></ul><ul><li>Dental ambulatory surgical claims denoting total surgical time in field 24 (billed on the CMS-1500 Form) </li></ul>
    17. 19. Electronic Funds Transfer <ul><li>Now mandatory for all providers </li></ul><ul><li>Faster access to funds </li></ul><ul><li>Eliminates possibility of lost or stolen check </li></ul><ul><li>Submit EFT form and a voided check to EDS </li></ul>
    18. 20. Annual MID Card Basic Medicaid Billing Guide, 2-7 through 8
    19. 21. Verification Methods <ul><li>EDI </li></ul><ul><ul><li>HIPAA transaction 270/271 </li></ul></ul><ul><ul><li>Real-time eligibility </li></ul></ul><ul><ul><li>Batch transaction </li></ul></ul><ul><li>NCECS </li></ul><ul><ul><li>Recipient Eligibility Verification Tool </li></ul></ul><ul><li>AVRS </li></ul><ul><ul><li>Recipient Eligibility and Coordination of Benefits </li></ul></ul><ul><ul><li>Option 6 </li></ul></ul><ul><ul><li>Appendix A </li></ul></ul>Basic Medicaid Billing Guide, 2-5 and Appendix F NEW!!
    20. 22. Recipient Eligibility Verification Tool <ul><li>Access through the NCECSWeb Tool </li></ul><ul><li>ECS Agreement required </li></ul><ul><li>Logon ID and password required </li></ul><ul><li>North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool September Special Bulletin </li></ul>NEW!! Basic Medicaid Billing Guide, Appendix F
    21. 23. NCECSWeb Access September 2009 Special Bulletin III, NCECS Submission/Recipient Eligibility Verification Web Tool Instruction Guide
    22. 24. Recipient Eligibility Inquiry
    23. 25. Eligibility Results Screen
    24. 26. Filing Adjustments Electronically <ul><li>Providers can file 2 types of adjustments </li></ul><ul><li>electronically: </li></ul><ul><ul><li>Void – claim will be recouped </li></ul></ul><ul><ul><li>Replacement – claim will be recouped and </li></ul></ul><ul><ul><li>reprocessed </li></ul></ul>
    25. 27. Dental Program Changes <ul><li>2009 Budget Bill (SL 2009-451) </li></ul><ul><li>Dental policy adjustments resulting in program cost savings of approximately $3.7 million in State appropriations </li></ul><ul><li>Refer to October 2009 Bulletin </li></ul><ul><li>All dental rates were reduced by 4.52% effective October 1, 2009 </li></ul>
    26. 28. Effective November 1, 2009 <ul><li>Limit panoramic films (D0330) to recipients ages 6 and older </li></ul><ul><li>Discontinue coverage of premolar sealants (D1351) for all recipients </li></ul>
    27. 29. Effective November 1, 2009 <ul><li>Reduce age limits for sealants (D1351) on all permanent molars from under age 21 to under age 16 </li></ul><ul><li>Reduce age limits for sealants (D1351) on primary molars from under age 10 to under age 8 </li></ul>
    28. 30. D2393 - Resin-Based Composite -three surfaces, posterior <ul><li>Effective November 1, 2009, allowed for primary and permanent teeth </li></ul><ul><li>For primary teeth, providers should consider rendering other covered restorative services (amalgam or stainless steel crown) when indicated due to extent of decay, behavior management concerns, inability to maintain a moisture-free field, high caries risk, etc. </li></ul>
    29. 31. Resin-Based Composite Restorations <ul><li>Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin </li></ul><ul><li>Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (e.g., diastemas, discolored teeth, developmental anomalies) </li></ul>
    30. 32. D2940 <ul><li>Sedative Filling </li></ul><ul><li>Not to be used as a temporary filling while awaiting completion of endodontic therapy </li></ul>
    31. 33. New Procedure Code D3222 <ul><li>Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development </li></ul><ul><li>Coverage effective 1/1/2009 </li></ul><ul><li>Refer to January 2009 Bulletin </li></ul><ul><li>Current reimbursement $81.09 </li></ul>
    32. 34. D3222 Limitations <ul><li>Limited to recipients under age 21 </li></ul><ul><li>Not allowed for the same tooth on the same date of service as D3220, D3230, D3240, D3310, D3320, or D3330 </li></ul><ul><li>Not to be construed as the first stage of root canal therapy </li></ul>
    33. 35. Effective November 1, 2009 D4341 and D4342 <ul><li>Periodontal scaling and root planing per quadrant </li></ul><ul><li>Each quadrant is allowed one (1) time per 12-month interval </li></ul><ul><li>Requires periodontal charting (pocket depth measurements must be greater than or equal to 4 mm) </li></ul>
    34. 36. Effective November 1, 2009 D4341 and D4342 <ul><li>Limited to no more than two (2) quadrants of scaling and root planing on the same date of service </li></ul><ul><li>This limitation does not apply to recipients treated in a inpatient hospital, outpatient hospital, or ambulatory surgical center </li></ul>
    35. 37. New Procedure Code D9612 <ul><li>Therapeutic parenteral drugs, two or more administrations, different medications </li></ul><ul><li>Coverage effective 11/1/2009 </li></ul><ul><li>Allowed for the administration of antibiotics, steroids, anti-inflammatory drugs, or other therapeutic medications when two or more different medications are necessary </li></ul>
    36. 38. D9612 Limitations <ul><li>Not allowed for the administration of sedatives, anesthetic, reversal agents, medications available in over-the-counter formulations, and prescription medications that can be self administered by the recipient prior to treatment </li></ul><ul><li>Identify drug, dosage, and rationale in the recipient’s dental record and on the claim form if filed as a paper claim </li></ul><ul><li>Not allowed on the same date of service as D9610 </li></ul>
    37. 39. Dental Seminar 2010 Properly Completing Prior Approval Requests
    38. 40. Doe, John W 10/01/1986 X 123456789L LL UR D4341 D4341 Periodontal Scaling & Root Planing Periodontal Scaling & Root Planing
    39. 41. X X X X X North Dental Clinic 123 Main St. City, NC 27999-9999 1234567890 919-555-4321 8999999 1987654321 I.M. Smiley, DDS, North Dental Clinic 123 Main St. City, NC 27999-9999 122300000X
    40. 42. Most Common Prior Approval Errors <ul><li>Field 34 Missing Teeth Information </li></ul><ul><li>Cross out (X) missing teeth </li></ul><ul><li>Slash (/) teeth to be extracted </li></ul><ul><li>Circle impacted teeth </li></ul><ul><li>Show space closure with arrows ( ) </li></ul>
    41. 43. Most Common Prior Approval Errors <ul><li>Box 52A Additional Provider ID </li></ul><ul><li>Instructions: Enter Medicaid billing provider number. This number is used for PA purposes only. </li></ul>
    42. 44. Most Common Prior Approval Errors <ul><li>Box 53 Signed (Treating Dentist) </li></ul><ul><li>Instructions: Signature or signature stamp of dentist requesting approval is required. </li></ul>
    43. 45. Most Common Prior Approval Errors <ul><li>Poor quality x-rays </li></ul><ul><li>All teeth are not visible on the x-rays </li></ul>
    44. 46. Good Quality X-Ray Example
    45. 47. Poor Quality X-Ray Example
    46. 48. Prior Approval Tips <ul><li>Submit all information with first mailing </li></ul><ul><ul><li>Send two copies of the request </li></ul></ul><ul><ul><li>Complete Chart 34 for partial dentures </li></ul></ul><ul><ul><li>Attach radiographs (bitewings, periapical films, panoramic film, or full mouth series) </li></ul></ul>
    47. 49. Prior Approval Tips <ul><li>Submit all information with first mailing </li></ul><ul><ul><li>Attach a periodontal charting </li></ul></ul><ul><ul><li>Attach any outstanding approvals that need voiding </li></ul></ul><ul><ul><li>Attach any medical documentation </li></ul></ul><ul><ul><li>Enter quadrant indicators (UR, UL, LL, LR) in Field 25 (area of the oral cavity) for all periodontal codes </li></ul></ul>
    48. 50. Tips for Orthodontic Prior Approval <ul><li>When resubmitting prior approval requests with additional information, include a new prior approval request, panoramic film, cephalometric film with tracing, models, and photos </li></ul><ul><li>Enter Medicaid Billing Provider Number in Field 52A on the banding prior approval request </li></ul>
    49. 51. When In Doubt… <ul><li>Contact HP Prior Approval Unit to avoid prior approval requests being returned multiple times for additional information </li></ul><ul><li>919-851-8888 or 1-800-688-6696 option 2, then 4 for dental or 7 for orthodontic </li></ul>
    50. 52. Dental Seminar 2010 Denial Notices
    51. 53. Denial Notices <ul><li>Service is denied due to </li></ul><ul><ul><li>a prior service </li></ul></ul><ul><ul><li>non-covered service (for recipients age 21 and older) </li></ul></ul><ul><ul><li>does not meet policy or EPSDT criteria </li></ul></ul><ul><ul><li>additional information requested was not received </li></ul></ul>
    52. 54. Denial Notices <ul><li>Notice is mailed to the recipient </li></ul><ul><li>A copy of the notice is mailed to the provider </li></ul><ul><li>Appeals must be returned within 30 days of the appeal letter </li></ul>
    53. 55. Denial Notice (Recipient Notification)
    54. 56. Notice of Additional Information <ul><li>If the prior approval request is returned to the provider for additional information, the recipient is sent a letter to inform them that additional information has been requested </li></ul><ul><li>The provider should return the requested information or request an extension within 15 business days of the date of the notice </li></ul>
    55. 57. Notice of Additional Information (Provider Notification)
    56. 58. Dental Seminar 2010 Test Your Dental Knowledge!
    57. 59. QUIZ TIME! <ul><li>How may copies of the prior approval request should a provider send? </li></ul>a. 5 b. 3 c. 2 d. 10
    58. 60. QUIZ TIME! <ul><li>When billing for appliances, what date of service must you use? </li></ul>a. impression date b. wax try-in date c. delivery date d. approval date
    59. 61. QUIZ TIME! <ul><li>What field on the ADA form is used for entering quadrant and arch indicators? </li></ul>a. 27 (tooth number or letter) b. 25 (area of oral cavity) c. 28 (tooth surface)
    60. 62. QUIZ TIME! <ul><li>Which of the following is acceptable data for Field 56A (Provider Specialty Code) on the ADA form? </li></ul>a. PHD b. Oral Surgeon c. 1223G0001X d. 8999999
    61. 63. Dental Seminar 2010 True or False
    62. 64. True or False? <ul><li>Obtaining prior approval does not guarantee payment. </li></ul>TRUE
    63. 65. True or False? <ul><li>Effective with date of service November 1, 2009, sealants on premolars are no longer covered. </li></ul>TRUE
    64. 66. True or False? <ul><li>The Billing Provider number is required in Field 52A for prior approval requests only. </li></ul>TRUE
    65. 67. True or False? <ul><li>Valplast partial dentures are not covered by NC Medicaid. </li></ul>TRUE
    66. 68. True or False? <ul><li>Unilateral (D1510) and bilateral (D1515) space maintainers should be billed using the tooth number(s) it replaces. </li></ul>FALSE
    67. 69. True or False? <ul><li>Providers must furnish a copy of treatment records when requested by any authorized Medicaid representative (i.e. DMA or HP). </li></ul>TRUE
    68. 70. Top 5 Claim Denials from Dental Providers And How to Avoid Them
    69. 71. EOB 191 <ul><li>Explanation: Recipient Name does not match Medicaid Identification Number </li></ul><ul><li>Resolution: Verify name of recipient by checking Eligibility Verification System, calling EDS Provider Services or checking MID card </li></ul>
    70. 72. EOB 143 <ul><li>Explanation: Medicaid ID number not on state eligibility file </li></ul><ul><li>Resolution: Verify name of recipient by checking Eligibility Verification System, calling EDS Provider Services or checking MID card </li></ul>
    71. 73. Unknown NPI <ul><li>Explanation: Provider submits an NPI that NC Medicaid does not have on file </li></ul><ul><li>Resolution: Verify NPI on NPI and Address Database </li></ul>
    72. 74. EOB 8326 <ul><li>Explanation: Attending Provider ID is missing or unresolved </li></ul><ul><li>Resolution: Submit an NPI in both billing and attending fields on claim </li></ul>
    73. 75. Dental Seminar 2010 Contacting Medicaid
    74. 76. Where do I send my…? <ul><li>Adjustments </li></ul><ul><ul><li>HP </li></ul></ul><ul><ul><li>PO Box 300009 </li></ul></ul><ul><ul><li>Raleigh, NC 27622 </li></ul></ul><ul><li>Prior Approvals </li></ul><ul><ul><li>HP </li></ul></ul><ul><ul><li>PO Box 31188 </li></ul></ul><ul><ul><li>Raleigh, NC 27622 </li></ul></ul><ul><li>Claims (paper) or Refunds </li></ul><ul><ul><li>HP </li></ul></ul><ul><ul><li>PO Box 300011 </li></ul></ul><ul><ul><li>Raleigh, NC 27622 </li></ul></ul>
    75. 77. I want a visit… who do I call? <ul><li>Marianne Diana – Provider Representative </li></ul><ul><li>Debbie LeBlanc – Provider Representative </li></ul><ul><li>ECS Representatives – billing electronically </li></ul><ul><ul><li>Alvis Tinnin – Eastern counties </li></ul></ul><ul><ul><li>Sandy Baglio – Western counties </li></ul></ul>1-800-688-6696 or 919-851-8888 Option 3
    76. 78. Contacting HP <ul><li>Call 1-800-723-4337 </li></ul><ul><ul><li>Automated Voice Response System </li></ul></ul><ul><li>Call 1-800-688-6696 or 919-851-8888 </li></ul><ul><ul><li>Press “1” – Electronic Commerce Services </li></ul></ul><ul><ul><li>Press “2” – Prior Approval </li></ul></ul><ul><ul><li>Press “3” – Provider Services </li></ul></ul><ul><ul><li>Press “0” – Operator </li></ul></ul>
    77. 79. Contacting DMA <ul><li>Recipient Eligibility-within 12 months </li></ul><ul><ul><li>Eligibility Verification Tool </li></ul></ul><ul><ul><li>AVRS – 1-800-723-4337 </li></ul></ul><ul><li>Recipient Eligibility-over 12 months </li></ul><ul><ul><li>DMA Claims Analysis – 919-855-4045 </li></ul></ul><ul><li>Questions about coverage policy </li></ul><ul><ul><li>DMA Dental Program – 919-855-4280 </li></ul></ul>
    78. 80. Question/Answer Session

    ×