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
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