GATEWAY Health Plan Dental Reference Guide

GATEWAY Health Plan Dental Reference Guide

Medical Assistance Program

Administered by United Concordia December 2009

GATEWAY HEALTH PLAN?

DENTAL REFERENCE GUIDE

TABLE OF CONTENTS

INTRODUCTION

SECTION 1 ? SUPPORT SERVICES

Communication Sources ........................................................................ 1.1

Dental Professional Relations Representatives ..................................... 1.1

Dental Customer Service Representatives ............................................ 1.2

Interactive Voice Response (IVR) System ............................................. 1.2

My Patients' Benefits.............................................................................. 1.3

Dental Reference Guide......................................................................... 1.3

Dentist Newsletter .................................................................................. 1.3

Special Mailings ..................................................................................... 1.4

Internet ................................................................................................... 1.4

Mailing Addresses for Claim and Prior Authorization Submissions........ 1.4

Mailing Addresses for Inquiries .............................................................. 1.5

Telephone Numbers............................................................................... 1.6

Helpful Websites .................................................................................... 1.6

SECTION 2 ? AUTOMATED SERVICES

My Patients' Benefits.............................................................................. 2.1

Interactive Voice Response (IVR) System ............................................. 2.1

Provider Check Information.................................................................... 2.2

Identification Cards................................................................................. 2.2

Confirm Eligibility.................................................................................... 2.3

DPW Eligibility Verification ..................................................................... 2.3

Member Benefit Packages ..................................................................... 2.3

Program Exception................................................................................. 2.4

SECTION 3 ? PARTICIPATING WITH SMILENET

Advantages of Participation.................................................................... 3.1

How to Become a Participating Dentist .................................................. 3.2

Confidentiality......................................................................................... 3.3

Credentialing .......................................................................................... 3.3

Internal Peer Review .............................................................................. 3.4

How Individual Provider ID Numbers Are Established ........................... 3.4

Group Practice ....................................................................................... 3.5

How to Form a Group Practice............................................................... 3.5

Medicaid DRG_11.20.09 Current Dental Terminology ? American Dental Association

Changes in Group Practice Membership / New Associates................... 3.6

Maintaining Dentist Data ........................................................................ 3.6

Where to Send Notification of Change(s)............................................... 3.7

How to Resign from Participation ........................................................... 3.7

Gateway Member's Rights and Responsibilities .................................... 3.7

Self-Referral ........................................................................................... 3.8

EPSDT Dental Referral .......................................................................... 3.8

Dental Referral ....................................................................................... 3.9

Specialty Care Providers........................................................................ 3.9

Example: Credentialing Application Example: Participating Dentist Agreement with SmileNet Example: Request for Dental Group Account (Addendum C) Example: Request for Addition and/or Deletion of a Participating Provider(s) Identification Number to an Existing Group Account (form 5704)

SECTION 4 ? POLICIES, LIMITATIONS AND EXCLUSIONS

Benefits and Exclusions - General Policies............................................ 4.1

Documentation Required For Specific Services..................................... 4.2

Prior Authorizations ................................................................................ 4.2

Requesting a Prior Authorization............................................................ 4.3

Full Benefit Coverage - Covered Services ............................................. 4.4

Full Benefit Coverage ? Benefits and Limitations................................. 4.13

Limited Benefit Coverage - Covered Services ..................................... 4.19

Limited Benefit Coverage ? Benefits and Limitations........................... 4.27

Procedure Code Reporting Chart......................................................... 4.43

Diagnostic Material Requirements Chart ............................................. 4.49

SECTION 5 ? ORTHODONTICS

Orthodontic Prior Authorizations ............................................................ 5.1

Orthodontic Treatment Plans ................................................................. 5.2

Orthodontic Services

Full Benefit Coverage ? Covered Services................................. 5.3

Benefits and Limitations for Orthodontic Services...................... 5.3

Payment for Orthodontic Services.......................................................... 5.4

Transferring Orthodontists.......................................................... 5.4

Orthodontic Treatment "In Progress".......................................... 5.4

New Enrollee .............................................................................. 5.4

Transferring from Another Dentist .............................................. 5.5

Billing Orthodontic Services ................................................................... 5.6

Billing for New Orthodontic Patients....................................................... 5.6

How to Complete a Dental Claim Form for New Orthodontic Patients... 5.6

Billing for New Patients "In Progress"..................................................... 5.7

Orthodontic Inquiries .............................................................................. 5.8

Example: Salzmann Index Report........................................................ 5.9

Medicaid DRG_11.20.09

Current Dental Terminology ? American Dental Association

Salzmann Index Instructions ................................................................ 5.11

SECTION 6 ? CLAIM SUBMISSION GUIDELINES

Completing the Claim Form.................................................................... 6.1

Claim Filing Deadline ............................................................................. 6.3

Gateway Health Plan? ID Number ......................................................... 6.3

Signature Requirements......................................................................... 6.4

Treatment Plan /Release of Information................................................. 6.4

Dentist's Signature ................................................................................. 6.4

Supporting Documentation..................................................................... 6.5

Other Supporting Documentation........................................................... 6.5

Prior Authorizations ................................................................................ 6.6

Requesting a Prior Authorization............................................................ 6.6

Prior Authorizations and Coordination of Benefits.................................. 6.7

Timeframes and Written Notification ...................................................... 6.7

Treatment without Prior Authorization .................................................... 6.8

Hospitalization / Short Procedure Unit (SPU) Procedure ....................... 6.8

Claim Review Process ........................................................................... 6.8

Initial Review .......................................................................................... 6.9

Professional Review by Dental Advisors................................................ 6.9

Example: Gateway Health Plan? Claim Form.................................... 6.10 Example: Dental Authorization Form for Medical Facility/Inpatient Services

SECTION 7 ? ELECTRONIC CLAIM SUBMISSION

Speed eClaimSM ..................................................................................... 7.1

Electronic Data Interchange (EDI).......................................................... 7.1

Benefits of Submitting Claims Electronically .......................................... 7.1

How to Become Eligible to Submit Electronic Claims ............................ 7.2

Submitting Claims Requiring Attachments ............................................. 7.3

Reports................................................................................................... 7.3

997 Functional Acknowledgement Report.................................. 7.3

277 Claims Acknowledgement Report ....................................... 7.3

835 Healthcare Claim Payment/Advice Report .......................... 7.4

National Provider Identifier (NPI)............................................................ 7.4

Example: NPI Questions and Answers Guide

SECTION 8 ? COORDINATION OF BENEFITS

Coordination of Medical Assistance (Medicaid) Benefits ...................... 8.1

SECTION 9 ? PAYMENTS AND REQUESTS FOR INFORMATION

Dental Explanation of Benefits (DEOB).................................................. 9.1

How to Read the DEOB ......................................................................... 9.1

Medicaid DRG_11.20.09

Current Dental Terminology ? American Dental Association

Requests for Additional Information Post Service Claims ...................... 9.2

Changing or Combining Reported Procedure Codes............................. 9.3

Example: Summary Payment Voucher ? Dental Explanation of Benefits (DEOB)

SECTION 10 ? APPEALS

Provider Appeal.................................................................................... 10.1

First Level Provider Appeal .................................................................. 10.1

Second Level Provider Appeal............................................................. 10.2

What May Not be Appealed ................................................................. 10.2

How to Request a Provider Appeal ...................................................... 10.2

Member Complaint Process ................................................................. 10.2

External Complaint Review .................................................................. 10.3

Expedited Complaint ............................................................................ 10.3

Provider Initiated Member Grievances ................................................. 10.3

Provider Responsibilities When Initiating Member Appeals ................. 10.4

Member Grievances: The First Level ................................................... 10.5

Member Grievances: The Second Level ............................................. 10.6

Expedited Grievances (Internal)........................................................... 10.8

Expedited Grievances (External).......................................................... 10.8

External Grievances (Standard) ........................................................... 10.9

DPW Fair Hearing .............................................................................. 10.10

Example: Gateway Health Plan? Consent Form

SECTION 11 ? BENEFIT SAFEGUARDS

Health Insurance Portability and Accountability Act (HIPAA)............... 11.1

Title VI of the Civil Rights Act of 1964 .................................................. 11.2

Important Rules and Regulations of the Standards for

Electronic Transactions ........................................................................ 11.2

HIPAA Privacy...................................................................................... 11.3

HIPAA Security..................................................................................... 11.3

Utilization Review (UR) ........................................................................ 11.3

Data Collection and Statistical Analysis ............................................... 11.3

The Utilization Review Process............................................................ 11.4

Professional Consultant Reviews......................................................... 11.4

Follow-up Actions ................................................................................. 11.4

Utilization Letters.................................................................................. 11.4

Fraud and Abuse.................................................................................. 11.5

Department of Public Welfare .............................................................. 11.6

Special Investigations Unit (SIU).......................................................... 11.7

Regulatory Compliance ........................................................................ 11.7

Coding and Billing ................................................................................ 11.7

Documentation and Record Keeping ................................................... 11.8

Medicaid DRG_11.20.09

Current Dental Terminology ? American Dental Association

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