A  New  Day For Oral Health In Virginia Spring 2006 Provider Training Seminars March 27 – 31, 2006
Agenda <ul><li>Welcome and Introductions </li></ul><ul><li>Program Performance Updates </li></ul><ul><li>Enrollee Eligibil...
Training Objectives <ul><li>Present updates regarding progress towards program goals and the latest changes to the program...
Program Overview:  Moving Successfully Toward the Goals
153 Additional Dentists Have Signed Up <ul><li>The network has increased from  620 to 773  individual providers with 1022 ...
Fee Schedule Increase – May 1, 2006 The 2005 General Assembly approved increased funding for dental rates effective May 1,...
Pediatric Dental Utilization <ul><li>Preliminary analysis indicates an upward trend in the number of children receiving ca...
Eligibility
Enrollee Eligibility <ul><li>Doral uses the 12-digit Medicaid ID number as the enrollee ID Number. </li></ul><ul><li>Eligi...
Enrollee Eligibility <ul><li>Issue:  After receiving confirmation of eligibility, a provider receives a denial of claim.  ...
Tips on Members’ Eligibility Verification <ul><li>It is recommended to verify eligibility in the month an appointment is s...
Prior Authorization
Minimal Authorization Requirements <ul><li>Prior-Authorization </li></ul><ul><li>Authorization and documentation submitted...
OR Authorizations <ul><li>Process to obtain an OR/SPU authorization: </li></ul><ul><li>To ensure timely processing, reques...
Orthodontic Review Process
Claims
Four Methods to Submit Claims   <ul><li>Electronic via Doral’s Internet Website: </li></ul><ul><li>Electronic via Clearing...
Claims Processing <ul><li>As a third party administrator, Doral pays claims upon receipt of funds from DMAS </li></ul><ul>...
Claims Processing: Required Information <ul><li>Most pertinent sections of the ADA form that  must  be completed in full i...
Orthodontic Claims <ul><li>The start and billing date is defined as the date when the bands, brackets, or appliances are p...
Claims Processing Calendar Claim Received Prior to Cut-off:
Claims Processing Calendar Claim Received After Cut-off:
Tips to Ensure Timely Payment <ul><li>Submit legible and correctly completed ADA claim forms  </li></ul><ul><li>Alert Dora...
Enrollee Outreach
Enrollee Access <ul><li>Find A Provider:   A provider search feature on the DMAS and Doral websites. A dentist can be loca...
Broken Appointments <ul><li>Broken appointments are: </li></ul><ul><ul><li>A major concern for DMAS, VDA, ODDS, and Doral ...
Appointment Reminder <ul><li>Mailed to enrollees who have not accessed care </li></ul><ul><li>Postcard mailing campaign </...
Provider Resources
Provider Directory <ul><li>Contents: </li></ul><ul><li>Provider name </li></ul><ul><li>Practice name </li></ul><ul><li>Off...
Interactive Phone System <ul><li>AVAILABLE 24 HOURS A DAY! </li></ul><ul><li>Dentists can access: </li></ul><ul><li>Patien...
Enhanced Automated Phone System <ul><li>Phone number to access this system:  1-888-912-3456, Option 1 </li></ul><ul><li>To...
Keep Doral Updated <ul><li>Accurate and up-to-date information is essential for appropriate referrals and claims payment. ...
Coming Soon!  Beginning Summer 2006, Doral will enhance its on-line services!
Electronic Funds Transfer (EFT) <ul><li>EFT permits the direct electronic deposit of  Smiles For Children  claim reimburse...
Provider Web-Site Enhancements <ul><li>Ability for providers to view status of claims and prior authorizations </li></ul><...
Contact Information <ul><li>Doral’s Smiles For Children Staff: </li></ul><ul><li>Cheryl Harris:   Direct Line:   (804) 217...
Thank You!
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A New Day For Oral Health In Virginia

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  • Be sure to bill at the new rate
  • Define Emergent -
  • A New Day For Oral Health In Virginia

    1. 1. A New Day For Oral Health In Virginia Spring 2006 Provider Training Seminars March 27 – 31, 2006
    2. 2. Agenda <ul><li>Welcome and Introductions </li></ul><ul><li>Program Performance Updates </li></ul><ul><li>Enrollee Eligibility </li></ul><ul><li>Prior Authorizations </li></ul><ul><li>Claims </li></ul><ul><li>Enrollee Outreach </li></ul><ul><li>Provider Resources </li></ul><ul><li>Doral’s Provider Website </li></ul><ul><li>Q & A </li></ul><ul><li>Training Evaluation </li></ul>
    3. 3. Training Objectives <ul><li>Present updates regarding progress towards program goals and the latest changes to the program </li></ul><ul><li>Clarify and address issues related to eligibility </li></ul><ul><li>Provide clarification regarding the prior authorization process for hospital cases </li></ul><ul><li>Outline the process for requesting authorization for orthodontic treatment </li></ul><ul><li>Review claims processes and procedures and provide helpful hints for timely reimbursement </li></ul><ul><li>Discuss issues related to enrollee access and introduce new enrollee outreach activities </li></ul><ul><li>Provide a brief overview of provider resources </li></ul><ul><li>Encourage greater utilization of the Doral provider website </li></ul>
    4. 4. Program Overview: Moving Successfully Toward the Goals
    5. 5. 153 Additional Dentists Have Signed Up <ul><li>The network has increased from 620 to 773 individual providers with 1022 practice locations ( As of February 28, 2006 ) </li></ul><ul><li>Six counties that previously had no participating dentists now have access to dental services: </li></ul><ul><ul><li>Amelia </li></ul></ul><ul><ul><li>Brunswick </li></ul></ul><ul><ul><li>Charles City </li></ul></ul><ul><ul><li>Highland </li></ul></ul><ul><ul><li>Madison </li></ul></ul><ul><ul><li>Prince George </li></ul></ul><ul><li>DMAS, Doral, the VDA and the Old Dominion Dental Society are continuing to enhance the Smiles For Children network </li></ul>
    6. 6. Fee Schedule Increase – May 1, 2006 The 2005 General Assembly approved increased funding for dental rates effective May 1, 2006. The Dental Advisory Committee decided to target endodontic and oral surgery codes as well as conscious sedation:
    7. 7. Pediatric Dental Utilization <ul><li>Preliminary analysis indicates an upward trend in the number of children receiving care </li></ul><ul><li>As of July 1, 2005, the percentage of enrolled providers who were treating Medicaid patients and filing claims was approximately 50%. Under the Smiles for Children program, this percentage is now approximately 75% </li></ul><ul><li>Through technology and improved customer service, enrollee access to dental providers has increased </li></ul>
    8. 8. Eligibility
    9. 9. Enrollee Eligibility <ul><li>Doral uses the 12-digit Medicaid ID number as the enrollee ID Number. </li></ul><ul><li>Eligibility may be confirmed using: </li></ul><ul><ul><li>Doral website </li></ul></ul><ul><ul><li>By calling 1-888-912-3456 </li></ul></ul><ul><ul><li>DMAS MediCall voice response system at 1-800-884-9730 or 1-800-772-9996. </li></ul></ul><ul><li>If DMAS Medicall voice response system is used, providers are cautioned to listen to the entire message . Members may be in a waiver program and not eligible for dental benefits. </li></ul>
    10. 10. Enrollee Eligibility <ul><li>Issue: After receiving confirmation of eligibility, a provider receives a denial of claim. The denial reason indicates “Member Not Found” </li></ul><ul><li>How has the issue been addressed: DMAS and Doral are now exchanging eligibility information weekly. DMAS and Doral are making modifications to the eligibility file to ensure data is complete and accurate. </li></ul><ul><li>Providers are encouraged to contact Doral if a claim is denied inappropriately. If eligibility can confirmed, the claim will be reprocessed and paid accordingly. </li></ul>
    11. 11. Tips on Members’ Eligibility Verification <ul><li>It is recommended to verify eligibility in the month an appointment is scheduled. </li></ul><ul><li>When using the website to verify eligibility, it is recommended that the verification be completed within 3 days prior to the date of service </li></ul><ul><li>Patients who turn 21 are eligible through the end of the month of their birthday. </li></ul><ul><li>Orthodontic patients are covered for the duration of the treatment if she/he was eligible on the date of banding . </li></ul>
    12. 12. Prior Authorization
    13. 13. Minimal Authorization Requirements <ul><li>Prior-Authorization </li></ul><ul><li>Authorization and documentation submitted before treatment begins </li></ul><ul><li>Authorization decision provided within 2 business days from the date the required documentation is received </li></ul><ul><li>For Hospital Dental services , authorization must be provided by Doral and the MCO, if applicable </li></ul><ul><ul><li>Authorization decision provided by Doral within 2 business days from the date the required documentation is received </li></ul></ul><ul><ul><li>Upon approval by Doral, required documentation is forwarded to MCO if applicable. Authorization decision provided by MCO within 2 business days from receipt of information from Doral </li></ul></ul><ul><li>Pre-payment Review </li></ul><ul><li>Requires proper documentation included with claim prior to consideration for payment </li></ul><ul><li>Option of requesting prior authorization if desired prior to rendering services </li></ul>
    14. 14. OR Authorizations <ul><li>Process to obtain an OR/SPU authorization: </li></ul><ul><li>To ensure timely processing, requests should be submitted on an ADA claim form and mailed to Doral at least 10 days prior to the date of service. </li></ul><ul><li>Clinically emergent requests should be marked as such and faxed to 262-834-3575 . </li></ul><ul><ul><li>Emergent care is defined as : A dental or oral condition that requires immediate services for relief of symptoms and stabilization of the condition; such conditions include severe pain; hemorrhage; acute infection; traumatic injury to the teeth and surrounding tissues; or unusual swelling of the face and gums. </li></ul></ul><ul><li>Medical necessity should be clearly stated. </li></ul><ul><li>Authorization of any services applicable to D9999 should be submitted along with the request for SPU preauthorization. </li></ul><ul><li>Doral is responsible for the coordination of the authorization process with the Managed Care Organizations. </li></ul><ul><li>Authorization determination letters for non-emergent care are mailed to the providers. </li></ul><ul><li>Authorization determination letters for emergent care are faxed to the provider. </li></ul><ul><li>Dentist/Dental Offices are responsible for ensuring the hospital receives authorization information. </li></ul>
    15. 15. Orthodontic Review Process
    16. 16. Claims
    17. 17. Four Methods to Submit Claims <ul><li>Electronic via Doral’s Internet Website: </li></ul><ul><li>Electronic via Clearinghouse: </li></ul><ul><ul><li>Affiliated Network Services (ANC) </li></ul></ul><ul><li>HIPAA compliant 837D File </li></ul><ul><li>Paper claims: </li></ul><ul><ul><li>Any ADA approved claim forms may be used (e.g. 1994, 2000, 2002-2004) </li></ul></ul>
    18. 18. Claims Processing <ul><li>As a third party administrator, Doral pays claims upon receipt of funds from DMAS </li></ul><ul><li>Contractual guidelines state that clean claims are to be processed within 30 days if receipt. </li></ul><ul><ul><li>A clean claim is defined as a complete claim that does not require any additional information to process it. </li></ul></ul><ul><ul><li>Doral’s average claims processing turnaround time: 19.18 Days </li></ul></ul><ul><li>Claims are processed according to processing cycle </li></ul><ul><li>Cut-off for claims processing cycle is every Tuesday at 4 p.m. </li></ul><ul><li>Processing cycle includes: </li></ul><ul><ul><li>Adjudication of claim </li></ul></ul><ul><ul><li>Reporting to DMAS </li></ul></ul><ul><ul><li>Approval of funds by DMAS </li></ul></ul><ul><li>Checks are cut upon approval of payment from DMAS </li></ul><ul><li>Checks are mailed upon receipt of funding from DMAS </li></ul>
    19. 19. Claims Processing: Required Information <ul><li>Most pertinent sections of the ADA form that must be completed in full in order to process your claims: </li></ul><ul><ul><li>Member’s information: </li></ul></ul><ul><ul><ul><li>Name </li></ul></ul></ul><ul><ul><ul><li>Address </li></ul></ul></ul><ul><ul><ul><li>Date of Birth </li></ul></ul></ul><ul><ul><ul><li>Subscriber ID Number </li></ul></ul></ul><ul><ul><li>Record of services provided: </li></ul></ul><ul><ul><ul><li>Date of service </li></ul></ul></ul><ul><ul><ul><li>Fee </li></ul></ul></ul><ul><ul><ul><li>Valid procedure code and a tooth number </li></ul></ul></ul><ul><ul><ul><li>Tooth surface or quadrant if the procedure code requires it </li></ul></ul></ul><ul><ul><li>Treating address </li></ul></ul><ul><ul><li>Treating provider </li></ul></ul><ul><ul><li>Billing entity’s information </li></ul></ul>
    20. 20. Orthodontic Claims <ul><li>The start and billing date is defined as the date when the bands, brackets, or appliances are placed in the member’s mouth. </li></ul><ul><li>If a member becomes ineligible during treatment and before full payment is made, Doral will pay the balance for any remaining treatment. </li></ul><ul><li>The maximum payment is 1 initial payment (D8080) and 3 quarterly periodic billed orthodontic treatments (D8670). </li></ul>
    21. 21. Claims Processing Calendar Claim Received Prior to Cut-off:
    22. 22. Claims Processing Calendar Claim Received After Cut-off:
    23. 23. Tips to Ensure Timely Payment <ul><li>Submit legible and correctly completed ADA claim forms </li></ul><ul><li>Alert Doral of any changes (i.e TIN, location, etc.) </li></ul><ul><li>Submit claims as soon after date of service as possible </li></ul><ul><li>Ensure that claim forms are filled out completely </li></ul><ul><li>When requested, be sure to use the treating location – not a P.O. Box </li></ul><ul><li>Use the patient’s name as shown on their ID Card/legal name – no nicknames </li></ul><ul><li>Claims must be submitted within 180 Days from the date of service or provider will face timely filing denials (Note: This is a change from the prior contract.) </li></ul>
    24. 24. Enrollee Outreach
    25. 25. Enrollee Access <ul><li>Find A Provider: A provider search feature on the DMAS and Doral websites. A dentist can be located within a certain mile radius from any given zip code. </li></ul><ul><li>Provider Directory: The provider directory is posted on the DMAS and Doral websites. </li></ul><ul><ul><li>A Provider Directory was mailed to recipients and all new recipients receive a copy. This is the first provider directory ever provided to Medicaid enrollees. </li></ul></ul><ul><li>eIVR: An enhanced automated phone system through a single 800 toll-free number. Members can verify eligibility and find a dentist through the automated system by entering a zip code. Services are available in Spanish and English. </li></ul><ul><li>Customer Service Representative: Members may also speak directly with a customer service representative for additional assistance during extended customer service hours. </li></ul>
    26. 26. Broken Appointments <ul><li>Broken appointments are: </li></ul><ul><ul><li>A major concern for DMAS, VDA, ODDS, and Doral </li></ul></ul><ul><ul><li>Recognized as expensive for dentists </li></ul></ul><ul><ul><li>Lead to dentists unwillingness to participate in the program </li></ul></ul><ul><li>Information is needed to better track, trend, and understand the issue </li></ul><ul><li>Doral will use the information to: </li></ul><ul><ul><li>Educate families regarding the importance of appointments and compliance with treatment plans </li></ul></ul><ul><li>Dentists can assist by completing the Broken Appointments Log and faxing to Doral’s Outreach Coordinator </li></ul><ul><li>Medicaid Transportation is available for dental appointments (contracted through the health plans) </li></ul>
    27. 27. Appointment Reminder <ul><li>Mailed to enrollees who have not accessed care </li></ul><ul><li>Postcard mailing campaign </li></ul><ul><ul><li>Alexandria </li></ul></ul><ul><ul><li>Norfolk </li></ul></ul><ul><ul><li>Richmond </li></ul></ul><ul><ul><li>Roanoke </li></ul></ul><ul><li>Targeted Mailing Date: 4th Quarter </li></ul>
    28. 28. Provider Resources
    29. 29. Provider Directory <ul><li>Contents: </li></ul><ul><li>Provider name </li></ul><ul><li>Practice name </li></ul><ul><li>Office address(es) </li></ul><ul><li>Telephone number(s) </li></ul><ul><li>Provider specialty </li></ul><ul><li>Panel status </li></ul><ul><li>Office hours </li></ul><ul><li>Languages spoken </li></ul><ul><li>Any other panel limitations </li></ul><ul><li>Directory may be downloaded from the DMAS website at : </li></ul><ul><li>http://www.dmas.virginia.gov/dental-home.htm </li></ul><ul><li>or </li></ul><ul><li>from the Doral website at: </li></ul><ul><li>http://www.doralusa.com </li></ul>
    30. 30. Interactive Phone System <ul><li>AVAILABLE 24 HOURS A DAY! </li></ul><ul><li>Dentists can access: </li></ul><ul><li>Patient Eligibility </li></ul><ul><li>Limited Claims History </li></ul><ul><li>Fax Back Confirmation of eIVR call </li></ul><ul><li>Spanish Call Handling </li></ul><ul><li>With eIVR, information can be obtained instantly and easily. </li></ul>
    31. 31. Enhanced Automated Phone System <ul><li>Phone number to access this system: 1-888-912-3456, Option 1 </li></ul><ul><li>To access eIVR, providers can login with: </li></ul><ul><ul><li>Location ID Number </li></ul></ul><ul><ul><li>Last 4 digits of the location TIN </li></ul></ul><ul><ul><li>Full location TIN and Last Name </li></ul></ul><ul><li>Patients eligibility can be verified on the eIVR along with limited claim history (codes: D0120, D0212, D0150, D0210, D0272, D274, D0330, D1110, D1120, D1201, D1203, D1204, D1205, D1351, D5110, D5120, D5130 and D5140) </li></ul><ul><li>Confirmation fax of the eIVR available to providers who use the system </li></ul><ul><li>Option to choose Spanish or English </li></ul>
    32. 32. Keep Doral Updated <ul><li>Accurate and up-to-date information is essential for appropriate referrals and claims payment. </li></ul><ul><li>Inform Doral of: </li></ul><ul><ul><li>Changes to your address, phone and fax numbers </li></ul></ul><ul><ul><li>New practice locations </li></ul></ul><ul><ul><li>Changes to Tax ID Number(s) </li></ul></ul><ul><ul><li>Plans to retire or terminate </li></ul></ul><ul><li>Alert Doral of broken appointments occurring in your practice </li></ul><ul><li>Send an application for new providers joining your practice at least 30 days prior to the effective date and respond to Doral’s credentialing requests in timely manner </li></ul><ul><li>Share you experiences (positive or negative) with us </li></ul><ul><li>Let us know what issues you would like addressed in our next session </li></ul>
    33. 33. Coming Soon! Beginning Summer 2006, Doral will enhance its on-line services!
    34. 34. Electronic Funds Transfer (EFT) <ul><li>EFT permits the direct electronic deposit of Smiles For Children claim reimbursements into a bank account designated by the provider whether claims are filed electronically or on paper </li></ul><ul><li>Advantages of EFT include: </li></ul><ul><ul><li>No lost checks or Post Office delay. </li></ul></ul><ul><ul><li>Savings of administrative and overhead costs. </li></ul></ul><ul><ul><li>No standing in line at the bank. </li></ul></ul><ul><ul><li>Faster access to funds; many banks credit direct deposits faster than paper checks </li></ul></ul><ul><ul><li>Easier reconciliation of payments with bank statements </li></ul></ul>
    35. 35. Provider Web-Site Enhancements <ul><li>Ability for providers to view status of claims and prior authorizations </li></ul><ul><li>Provider information component, including: </li></ul><ul><ul><li>On-line newsletter </li></ul></ul><ul><ul><li>Program Information </li></ul></ul>Enhanced services will include:
    36. 36. Contact Information <ul><li>Doral’s Smiles For Children Staff: </li></ul><ul><li>Cheryl Harris: Direct Line: (804) 217-8344 </li></ul><ul><li>Project Director Fax: (804) 217-8348 </li></ul><ul><li>Email: [email_address] </li></ul><ul><li>Anna Perez: Direct Line: (804) 217-8392 </li></ul><ul><li>Provider Relations Representative Fax: (804) 217-8349 </li></ul><ul><li>Email: [email_address] </li></ul><ul><li>Kristen Fincher: Direct Line: (804) 935-8589 </li></ul><ul><li>Outreach Coordinator Fax: (804) 217-8350 </li></ul><ul><li>Email: [email_address] </li></ul><ul><li>DMAS’ Smiles For Children Staff: </li></ul><ul><li>Sandra Brown: Direct Line: (804) 786-1567 </li></ul><ul><li>Dental Program Manager Email: [email_address] </li></ul><ul><li>Lisa Bilik: Direct Line: (804) 786-7956 </li></ul><ul><li>Dental Contract Monitor Email: [email_address] </li></ul><ul><li>Dr. Stephen Riggs, DDS: Direct Line: (804) 786-6635 </li></ul><ul><li>Dental Consultant Email: [email_address] </li></ul>
    37. 37. Thank You!

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