WellCare NJ FamilyCare (NJFC) Provider Reference Guide

WellCare NJ FamilyCare (NJFC)

Provider Reference Guide

TABLE OF CONTENTS

SECTION 1. LIBERTY DENTAL PLAN INFORMATION .................................................................................................. 5

INTRODUCTION ................................................................................................................................................................... 5 OUR MISSION.......................................................................................................................................................................5 PROVIDER CONTACT AND INFORMATION GUIDE ........................................................................................................6 NEW JERSEY PROVIDER RELATIONS TERRITORY ASSIGNMENT .....................................................................................7 SECTION 2. PROVIDER RELATIONS AND PROVIDER TRAINING................................................................................ 8

PROVIDER COMPLIANCE AND TRAINING ......................................................................................................................9 SECTION 3. ONLINE SELF-SERVICE TOOLS ............................................................................................................. 10

ON-LINE ACCOUNT ACCESS ..........................................................................................................................................10 DIRECTORY INFORMATION VERIFICATION (DIV) ONLINE ..........................................................................................11 SECTION 4. ELIGIBILITY........................................................................................................................................... 12

HOW TO VERIFY ELIGIBILITY .............................................................................................................................................12 MEMBER IDENTIFICATION CARDS ..................................................................................................................................12 PRIMARY CARE DENTAL ASSIGNMENT ..........................................................................................................................13 SECTION 5. MEDICAID PROGRAM GUIDELINES..................................................................................................... 14

DEFINITION OF MEDICAL NECESSITY..............................................................................................................................14 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES......................................................15 NJ SMILES PROGRAM ......................................................................................................................................................17 NJ FAMILYCARE PROGRAM ...........................................................................................................................................17 NJ FAMILYCARE INCOME CHART..................................................................................................................................18 CARE FOR MEMBERS WITH SPECIAL NEEDS..................................................................................................................18 NJ FAMILYCARE SCOPE OF BENEFITS............................................................................................................................20 NJ FAMILYCARE (NJFC) REIMBURSEMENT ....................................................................................................................21 CONTINUITY OF CARE......................................................................................................................................................21 REFERRALS.......................................................................................................................................................................... 22 SECOND OPINIONS..........................................................................................................................................................23 OWNERSHIP AND CONTROL DISCLOSURE ...................................................................................................................23 SECTION 6. CLAIMS AND BILLING ......................................................................................................................... 24

ELECTRONIC SUBMISSION ? CLAIMS, PRIOR AUTHORIZATIONS AND REFERRALS...................................................24 PAPER CLAIMS ..................................................................................................................................................................25

CLAIMS SUBMISSION ........................................................................................................................................................25

DATE OF INSERTION..........................................................................................................................................................25

NATIONAL PROVIDER IDENTIFIER....................................................................................................................................25 CLAIMS STATUS INQUIRY..................................................................................................................................................26

CLAIMS STATUS EXPLANATIONS .....................................................................................................................................26

CLAIMS RESUBMISSION ....................................................................................................................................................26 CLAIMS OVERPAYMENT ..................................................................................................................................................26

OFFSET TO PAYMENTS ......................................................................................................................................................27

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PROVIDER PAYMENTS THROUGH ECHO HEALTH, INC................................................................................................27 PEER-TO-PEER COMMUNICATION .................................................................................................................................28 SECTION 7. COORDINATION OF BENEFITS ............................................................................................................ 29

MULTIPLE CARRIERS ..........................................................................................................................................................29 SECTION 8. PROFESSIONAL GUIDELINES AND STANDARDS OF CARE................................................................... 30

GENERAL DENTIST PROVIDER RESPONSIBILITIES ...........................................................................................................30 SPECIALTY CARE PROVIDERS RESPONSIBILITIES ...........................................................................................................31 MEMBER RIGHTS AND RESPONSIBILITIES ........................................................................................................................31 VOLUNTARY PROVIDER CONTRACT TERMINATION ....................................................................................................32 MOBILE DENTAL PRACTICES AND MOBILE DENTAL VANS .........................................................................................32 STANDARDS OF ACCESSIBILITY AND AVAILABILITY .....................................................................................................33 AFTER HOURS AND EMERGENCY SERVICES AVAILABILITY .........................................................................................34 APPOINTMENT RESCHEDULING ......................................................................................................................................34 COMPLIANCE WITH THE STANDARDS OF ACCESSIBILITY AND AVAILABILITY..........................................................35 RECALL, FAILED OR CANCELLED APPOINTMENTS ......................................................................................................35 FACILITY PHYSICAL ACCESS FOR THE DISABLED ? AMERICANS WITH DISABILITIES ACT........................................35 TREATMENT PLAN GUIDELINES ........................................................................................................................................35 CONTINUITY AND COORDINATION OF CARE .............................................................................................................36 MEDICAL REFERRALS........................................................................................................................................................36 INFECTION CONTROL ......................................................................................................................................................36 THE DENTAL RECORD.......................................................................................................................................................36 DENTAL RECORDS AVAILABILITY ....................................................................................................................................37 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA).................................................................38 SAFEGUARDING PROTECTED HEALTH INFORMATION (PHI).......................................................................................38 ANTI-DISCRIMINATION .....................................................................................................................................................40 CULTURALLY COMPETENT CARE ....................................................................................................................................41 LANGUAGE ASSISTANCE SERVICES ...............................................................................................................................41 SECTION 9. REFERRAL AND PRIOR AUTHORIZATION GUIDELINES.......................................................................... 43

PRIOR AUTHORIZATION GUIDELINES FOR GENERAL DENTISTS...................................................................................43 NON-EMERGENCY SPECIALTY REFERRAL .....................................................................................................................44 EMERGENCY REFERRAL ...................................................................................................................................................45 REFERRALS TO SPECIALISTS BY THE PRIMARY CARE DENTIST......................................................................................45 PRIOR AUTHORIZATION GUIDELINES FOR PROCEDURES WHICH MAY BE PROVIDED BY EITHER A DENTAL SPECIALIST OR A PHYSCIAN...............................................................................................................47 PRIOR AUTHORIZATION GUIDELINES FOR TREATMENT IN THE OPERATING ROOM AND AMBULATORY SURGICAL CENTER FOR MEMBERS WITH SPECIAL HEALTH CARE NEEDS (SHCN) ......................................................................47 SECTION 10. CLINICAL DENTISTRY PRACTICE PARAMETERS ................................................................................ 51

NEW MEMBER INFORMATION.........................................................................................................................................51 CLINICAL ORAL EVALUATIONS.......................................................................................................................................55 INFORMED CONSENT.......................................................................................................................................................55 DIAGNOSTIC IMAGING ...................................................................................................................................................56

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TESTS, EXAMINATIONS AND REPORTS ............................................................................................................................57 PREVENTIVE TREATMENT ..................................................................................................................................................57 RESTORATIVE TREATMENT ................................................................................................................................................57 ENDODONTICS.................................................................................................................................................................. 61 PERIODONTICS .................................................................................................................................................................. 63 REMOVABLE PROSTHETICS..............................................................................................................................................66 IMPLANTS ...........................................................................................................................................................................68 FIXED PROSTHODONTICS ................................................................................................................................................69 ORAL SURGERY .................................................................................................................................................................69 ORTHODONTICS ...............................................................................................................................................................71 ADJUNCTIVE SERVICES ....................................................................................................................................................78 RETROSPECTIVE REVIEW ..................................................................................................................................................81 SECTION 11. QUALITY MANAGEMENT................................................................................................................... 82

COMPLIANCE STATEMENT ..............................................................................................................................................82 UTILIZATION MANAGEMENT............................................................................................................................................82 PROHIBITED ACTIONS.......................................................................................................................................................83 MEMBER APPEALS.............................................................................................................................................................83 TEMPORARY CHANGES TO THE APPEAL PROCESS DURING COVID-19 ..................................................................88 PROVIDER GRIEVANCES..................................................................................................................................................90 PROVIDER APPEALS..........................................................................................................................................................90 AVAILABILITY OF ASSISTANCE.........................................................................................................................................91 TIMELY FILING ....................................................................................................................................................................91 FORMS ................................................................................................................................................................................91 PROGRAM FOR INDPENDENT CLAIM PAYMENT ARBITRATION (PICPA) ..................................................................91 SECTION 12. FRAUD WASTE AND ABUSE ............................................................................................................... 92

COMPLIANCE STATEMENT ..............................................................................................................................................92 FRAUD, WASTE, AND ABUSE PROGRAM DESCRIPTION ..............................................................................................92 SECTION 13. FORMS AND RESOURCES .................................................................................................................. 96

SECTION 14. BENEFITS SCHEDULE .......................................................................................................................... 97

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SECTION 1. LIBERTY DENTAL PLAN INFORMATION

INTRODUCTION Welcome to LIBERTY Dental Plan's ("LIBERTY") network of Participating Providers. We are proud to maintain a broad network of qualified dental providers who offer both general and specialized treatment, guaranteeing widespread access to WellCare members.

The intent of this Provider Reference Guide is to aid each Participating Provider and their staff members in becoming familiar with the administration of LIBERTY dental plans. Please note that this Provider Reference Guide serves only as a summary of certain terms of the Provider Agreement between you (or the contracting dental office/facility) and LIBERTY and that additional terms and conditions of the Provider Agreement may apply. In the event of a conflict between a term of this Provider Reference Guide and a term of the Provider Agreement, the term of the Provider Agreement shall supersede this Provider Reference Guide. You received a copy of the fully executed Provider Agreement at the time of your activation on LIBERTY's network or when you were oriented to the Plan; however, you may also obtain a copy of the Provider Agreement at any time by submitting a request to PRinquiries@ or by contacting the Provider Relations Department.

In order to provide the most current information, updates to the Provider Reference Guide will be available on the LIBERTY website at .

OUR MISSION LIBERTY is committed to be the industry leader in providing quality, innovative and affordable dental benefits with the utmost focus on member satisfaction.

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