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

Office Standards of Care...................................................................... 11.8

Recall System ...................................................................................... 11.8

Accessibility.......................................................................................... 11.9

Continuity and Coordination of Care .................................................... 11.9

Members with Primary Care Needs ..................................................... 11.9

Americans with Disabilities Act ? Effective Communication................. 11.9

Special Needs / Care Management General Information................... 11.10

Office Environment............................................................................. 11.12

Sterilization and Asepsis Control........................................................ 11.13

55 PA Code, Chapter 1101 General Provisions................................. 11.13

Advanced Directives .......................................................................... 11.13

Recipient Restriction Program ........................................................... 11.14

SECTION 12 ? GLOSSARY OF TERMS

Medicaid DRG_11.20.09

Current Dental Terminology ? American Dental Association

GATEWAY HEALTH PLAN?

Welcome to Gateway Health Plan?

Gateway Health Plan? (Gateway) was established in 1992 to provide a managed care option to Medical Assistance recipients in Pennsylvania. United Concordia is pleased that we are able to offer Medical Assistance recipients, who choose Gateway, quality dental care through the support of the SmileNet dental network, starting November 2007.

The dental benefit package offered through United Concordia includes all Medical Assistance benefits for Gateway members. For members age 21 and over, Gateway offers either a Full or Limited Benefit package, depending upon the member's Medical Assistance benefit category. When providing care for members, please check eligibility prior to each appointment as benefit coverage may change from one package to the other or terminate altogether. Eligibility may be confirmed through My Patients' Benefits, our Interactive Voice Response (IVR) System, or by contacting our Dental Customer Service department at 1-866-568-5467. Information on eligibility confirmation may be found in Support Services, Section 1.

Should Gateway members have questions regarding their general benefits, benefit package, or policies and procedures on grievances, complaints, or Department of Public (DPW) Fair Hearings, please refer the member to the Gateway Member Services Department at 1-800-392-1147. Members may also use this number to request a copy of the Gateway Member Handbook. This number is designated for member use only. Information on grievances, complaints and DPW Fair Hearings is also available in Appeals, Section 10.

We value your participation in the SmileNet Network. Our experienced staff works hard to make your interactions with us as simple and seamless as possible. And, we continually seek new and innovative offerings to better serve you.

We look forward to providing quality service and support to you and your office.

Medicaid DRG_11.20.09

Current Dental Terminology ? American Dental Association

About the Dental Reference Guide

United Concordia and Gateway realize that the success of our partnership is dependent upon communication and educational processes. The Gateway Dental Reference Guide is designed to provide you and your office staff with information about United Concordia's policies and procedures used to administer dental benefits for Gateway Health Plan? members. This document is intended to provide a general guideline for your office, as well as your source for eligibility, coverage, policies, procedures, procedure codes, claims and payments. Familiarity with the concepts, procedures and policies in this manual will ensure proper and efficient administration. If you find anything in this manual which you feel is unclear, please contact your Professional Relations Network Representative at 1-866-568-6098. Please retain all updates with your manual.

Medicaid DRG_11.20.09

Current Dental Terminology ? American Dental Association

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