Top 3 Appeal Categories 1. Denial of Orthodontic Services (55) 2. Denial of Partial Dentures (5) 3. Denial of Crown (4) Members submitted 42 appeals to DMAS. In those cases where a hearing was held, the Hearing Officer upheld all decisions made by Doral.
Provider Grievances & Appeals
Top 3 Grievance Categories
Claims Denial (17)
Reimbursement Issue (10)
Member Eligibility (8)
Authorization Denial (8)
Top 3 Appeal Categories 1. Denial of Orthodontic Services (26) 2. Denial of Upcoded Extraction (3) 3. Denial of Crown (2) DMAS did not receive any appeals from providers.
Doral introduced the Broken Appointment Log at the Spring 2006 Provider Training Session held in March:
Broken Appointments are defined as those appointments that are not rescheduled or cancelled in accordance with the provider’s office policies.
Broken Appointment Log also featured in DMAS’ Spring 2006 Program Update Memo and Doral’s Smiles For Children Provider Newsletter.
Doral’s Office Reference Manual (ORM) updated to include the form.
A copy of the form can be downloaded from the DMAS website at: http://www.dmas.virginia.gov
Dental Check Up Reminder
Dental Check up Reminder postcards were mailed to all enrollees with no record of receiving services from July 1, 2005 – April 26, 2006.
34,443 5,997 June 2006 Roanoke City 2,710 June 2006 Alexandria City 13,293 May 2006 Norfolk City 12, 443 May 2006 Richmond City Total Mailed Month Mailed Area Dental Exam Reminder Postcard Mailings
Dental Network Overview
New Smiles For Children Dentists
Between July 1, 2005 – June 30, 2006, 190 additional dentists enrolled in the program. This represents a 30.64% increase in the network.
From 620 to 810
As of July 31, the total number of additional dentists that have signed up is:
This brings the total number of enrolled providers to 821, which represents a 32.41% increase).
From 620 to 821
Distribution of Providers By Specialty
Summary of Key Recruitment Activities
Provider Meetings and Office Visits:
DMAS and Doral visited more than 130 provider offices located in each region. In the 4 th quarter, various specialty providers such as Orthodontists, Oral Surgeons, and Endodontists were targeted.
Application assistance activities (dropping off and picking up applications) implemented
Virginia Dental Association (VDA) Component Meetings:
DMAS and Doral attended at least one meeting held by each of the VDAs eight (8) components as well as attended the VDA Annual Conference.
Old Dominion Dental Society (ODDS) Meetings:
DMAS and Doral attended meetings held by two (2) of the ODDS components as well as attended the ODDS Annual Conference.
Provider Verification Project:
Pre-populated forms mailed to 990 provider locations to verify information regarding the provider name, practice name, office addresses(s), telephone number(s), provider specialty, panel status, office hours, and any other panel limitations as directed by the provider:
Implemented production of monthly updated provider directory. Available electronically or printed hard copy.
Summary of Key Recruitment Activities (cont.)
Strategic Planning with Community Partnerships :
FAMIS Outreach Project led by the Partnership for Access to Health Care (PATH), Radford, VA: Collaborated with PATH and provided recruitment materials. Group conducted a door-to-door campaign to recruit dentists in southwestern Virginia.
Virginians for Improving Access to Dental Care (VIADC), Richmond, VA: Participated through membership on VIADC and various sub-committees. Quarterly presentation on SFC program updates was added as a standing agenda item.
Virginia Department of Health (VDH) Richmond, VA: Provided reports to VDH to assist with monitoring Dentists participating in the Loan Repayment Program. VDH assisted Doral in securing locations for Non-Participating Provider Informational Seminars.
VCU Dental School: Conducted brief presentation to 3 rd year dental students. Participated in VCU Clinic Day.
Virginia Primary Care Association, Richmond, VA: Participated in annual conference. Primary goals were provider recruitment and increasing program awareness.
Virginia Rural Health Association, Blacksburg, VA: Participated in annual conference. Primary goals were provider recruitment and increasing program awareness.
Mission of Mercy (MOM): Participated in the MOM-Eastern Shore, MOM-Northern Virginia, and MOM-Wise events. Primary goals were provider recruitment and increasing program awareness.
Summary of Key Recruitment Activities (cont.)
Communications and Mailings:
DMAS and Doral completed several mailings to providers regarding such topics as:
Provider recruitment: Letters sponsored by DMAS/VDA/ODDS
Fee Schedule Increase
Electronic Funds Transfer
Recruitment and Retention Phone Calls:
More than 1,000 recruitment phone calls and countless retention calls have been made to licensed dental providers.
Current & Future Network Strategies
Development of provider to enrollee ratios and needs assessment currently underway. Results will identify the adequacy of network and areas requiring more focused recruitment.
Conduct at least one Informational Meeting per region: Northern, Northwest, Southwest, Eastern, Central
Outreach initiated in the Eastern Region (Suffolk).
Continue provider office visits and application assistance
Continue attendance/presentation at Virginia Dental Association, Old Dominion Dental Society, and Specialty Organization Meetings
NEWS AND UPDATES
Electronic Funds Transfer (EFT)
Doral had anticipated a summer roll-out of the EFT process, but as we delved into the process we learned two things:
EFT would truly be a benefit to providers when an electronic remittance would also be available in order for providers to appropriately apply payments. In order to be most effective, Doral decided it would be best to roll out EFT and electronic remittance at the same time.
Significant system development is required to ensure an effective, efficient, error-free transition to these electronic processes.
Doral is currently analyzing the project scope and resources. Doral will be working with a vendor on this project. At this time, a Fall 2007 release date is anticipated.
National Provider Identifier (NPI)
DMAS is adopting the NPI as the standard for identifying all providers on all transactions, including paper.
To prepare for the transition to the NPI, Doral and DMAS are targeting January 22, 2007 as the starting date for using NPIs in transactions from providers and trading partners.
Beginning May 23, 2007, the NPI is required to be in Doral’s system in order to do business with and receive reimbursement for services under the Smiles For Children program.
Currently, 110 NPI forms have been received.
Provider Web-Site Enhancement
Doral can now receive electronic preauthorization requests directly on Doral’s website or when submitted through a clearinghouse.
The electronic preauthorization request must be submitted with the required electronic attachments.
Electronic attachments can be sent to Doral Dental using National Electronic Attachment (NEA) FastAttach.