2Introduction DMA Website Medicaid Updates Properly Completing Prior Approval RequestsDenial NoticesTest Your Dental KnowledgeTop Five Claim DenialsContacting MedicaidHave them look at their Agenda page – and the back of the page for contact information.
12Budget InitiativesCheck website before each seminar, read each initiative so we summarize what we cover today.It is being updated DAILY!!!!!8/28/09:Enrollment Fees for ProvidersPaperless Commerce (including)Electronic PaymentsMedicaid Uniform Screening Tool for PASARRProgram Reductions/Service LimitationsRecipient Medicaid Identification CardsNCECS Recipient Eligibility Verification Tool – Sept 2009 Bulletin
13Provider EnrollmentCSC (Computer Sciences Corporation) assumed responsibilities from DMA in April 2009Contact Information:Phone:Fax:Website:
14Enrollment Verification Information was mailed to providers in December of 2009Medicaid providers who have not been credentialed in the last 18 monthsInformation should have been verified and returned to CSC within 30 days
15Budget InitiativesCheck website before each seminar, read each initiative so we summarize what we cover today.It is being updated DAILY!!!!!8/28/09:Enrollment Fees for ProvidersPaperless Commerce (including)Electronic PaymentsMedicaid Uniform Screening Tool for PASARRProgram Reductions/Service LimitationsRecipient Medicaid Identification CardsNCECS Recipient Eligibility Verification Tool – Sept 2009 Bulletin
16Electronic Claims Submission Mandatory as of October 2, 2009Cost saving measureRefer to the October 2009 bulletinECS Agreement
17Electronic Claims Exceptions Any dental claim billed with one of the following ADA procedure codes:D0340D0470D8680Unclassified and unlisted procedures:D7999This may change as exceptions are identified – so review often!!!!Exceptions LISTThere will still be EOBs that require medical records or attachments – you will initially need to submit them on paper if not on this list.You will need an ICN from the denial to resubmit the claim on paper. Follow the instructions for the specific EOB receivedRemember to review this – Definitely before sending any paper claims -----AGAIN follow the instructions on the EOB of the electronic denial if you are submitting a paper claim for claims not on this list!!!!!!!
18Electronic Claim Exceptions Undelivered denturesDental claims for special consideration tooth number reviewsDental assistant surgeon claims with recordsDental ambulatory surgical claims denoting total surgical time in field 24 (billed on the CMS-1500 Form)
19Electronic Funds Transfer Now mandatory for all providersFaster access to fundsEliminates possibility of lost or stolen checkSubmit EFT form and a voided check to EDS
20Annual MID Card Basic Medicaid Billing Guide, 2-7 through 8 New look/layout to MID cardANNUALNo longer serves as proof of eligibilityMust utilize one of the above methods to verify eligibilityBasic Medicaid Billing Guide, 2-7 through 8
21Verification Methods EDI NCECS AVRS HIPAA transaction 270/271 Real-time eligibilityBatch transactionNCECSRecipient Eligibility Verification ToolAVRSRecipient Eligibility and Coordination of BenefitsOption 6Appendix ASummarize each method, will review in detail in a moment …NEW!!Basic Medicaid Billing Guide, 2-5 and Appendix F
22Recipient Eligibility Verification Tool NEW!!Access through the NCECSWeb ToolECS Agreement requiredLogon ID and password requiredNorth Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool September Special BulletinBasic Medicaid Billing Guide, Appendix F
23NCECSWeb AccessSeptember 2009 Special Bulletin III, NCECS Submission/Recipient Eligibility Verification Web Tool Instruction Guide
24Recipient Eligibility Inquiry Screen shot of recipient eligibility inquiry4 options to search with available criteriaCURRENT MONTH ELIGIBILITY
26Filing Adjustments Electronically Providers can file 2 types of adjustmentselectronically:Void – claim will be recoupedReplacement – claim will be recouped andreprocessedWhen submitting electronic adjustments, you have two choices. Void (explain) and Replacement (explain).26
27Dental Program Changes 2009 Budget Bill (SL )Dental policy adjustments resulting in program cost savings of approximately $3.7 million in State appropriationsRefer to October 2009 BulletinAll dental rates were reduced by 4.52% effective October 1, 2009
28Effective November 1, 2009Limit panoramic films (D0330) to recipients ages 6 and olderDiscontinue coverage of premolar sealants (D1351) for all recipients
29Effective November 1, 2009Reduce age limits for sealants (D1351) on all permanent molars from under age 21 to under age 16Reduce age limits for sealants (D1351) on primary molars from under age 10 to under age 8
30D2393 - Resin-Based Composite -three surfaces, posterior Effective November 1, 2009, allowed for primary and permanent teethFor primary teeth, providers should consider rendering other covered restorative services (amalgam or stainless steel crown) when indicated due to extent of decay, behavior management concerns, inability to maintain a moisture-free field, high caries risk, etc.
31Resin-Based Composite Restorations Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentinResin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (e.g., diastemas, discolored teeth, developmental anomalies)Read these 2 statements out loud because they’re new statements in the manual.
32D2940Sedative FillingNot to be used as a temporary filling while awaiting completion of endodontic therapy
33New Procedure Code D3222Partial pulpotomy for apexogenesis – permanent tooth with incomplete root developmentCoverage effective 1/1/2009Refer to January 2009 BulletinCurrent reimbursement $81.09
34D3222 Limitations Limited to recipients under age 21 Not allowed for the same tooth on the same date of service as D3220, D3230, D3240, D3310, D3320, or D3330Not to be construed as the first stage of root canal therapy
35Effective November 1, 2009 D4341 and D4342 Periodontal scaling and root planing per quadrantEach quadrant is allowed one (1) time per 12-month intervalRequires periodontal charting (pocket depth measurements must be greater than or equal to 4 mm)To be approved for D4341 (4 or more teeth – per quadrant) – there must be at least 4 teeth in the quadrant that have pockets depths of 4mm or greater.To be approved for D4342 (1 -3 teeth – per quadrant) – there must be 1-3 teeth in the quadrant that have pocket depths of 4mm or greater.
36Effective November 1, 2009 D4341 and D4342 Limited to no more than two (2) quadrants of scaling and root planing on the same date of serviceThis limitation does not apply to recipients treated in a inpatient hospital, outpatient hospital, or ambulatory surgical center
37New Procedure Code D9612Therapeutic parenteral drugs, two or more administrations, different medicationsCoverage effective 11/1/2009Allowed for the administration of antibiotics, steroids, anti-inflammatory drugs, or other therapeutic medications when two or more different medications are necessary
38D9612 LimitationsNot allowed for the administration of sedatives, anesthetic, reversal agents, medications available in over-the-counter formulations, and prescription medications that can be self administered by the recipient prior to treatmentIdentify drug, dosage, and rationale in the recipient’s dental record and on the claim form if filed as a paper claimNot allowed on the same date of service as D9610
48Prior Approval Tips Submit all information with first mailing Send two copies of the requestComplete Chart 34 for partial denturesAttach radiographs (bitewings, periapical films, panoramic film, or full mouth series)
49Prior Approval Tips Submit all information with first mailing Attach a periodontal chartingAttach any outstanding approvals that need voidingAttach any medical documentationEnter quadrant indicators (UR, UL, LL, LR) in Field 25 (area of the oral cavity) for all periodontal codes
50Tips for Orthodontic Prior Approval When resubmitting prior approval requests with additional information, include a new prior approval request, panoramic film, cephalometric film with tracing, models, and photosEnter Medicaid Billing Provider Number in Field 52A on the banding prior approval request
51When In Doubt…Contact HP Prior Approval Unit to avoid prior approval requests being returned multiple times for additional informationor option 2, then 4 for dental or 7 for orthodontic
52Dental Seminar 2010 Denial Notices Our next section is on Denial Notices
53Denial Notices Service is denied due to a prior service non-covered service (for recipients age 21 and older)does not meet policy or EPSDT criteriaadditional information requested was not receivedIf a request for prior approval is denied because-(read each bullet point)
54Denial Notices Notice is mailed to the recipient A copy of the notice is mailed to the providerAppeals must be returned within 30 days of the appeal letter
55Denial Notice (Recipient Notification) Here’s what the recipient letter looks like. The provider letter looks very similar.
56Notice of Additional Information If the prior approval request is returned to the provider for additional information, the recipient is sent a letter to inform them that additional information has been requestedThe provider should return the requested information or request an extension within 15 business days of the date of the noticeThis type of notification is not really a denial – it’s a Notice of Additional Information which means the PA dept. can’t go any further with their decision until they get additional information.A letter is sent to the provider and the recipient informing them as such.The provider should return the requested information or request an extension within 15 business days of the date of the notice.If the requested information or request for an extension is not received within the 15 business days of the date of the notice, the request will be denied on day 16.
57Notice of Additional Information (Provider Notification) This is what the letter to the provider looks like – the recipient also receives a notification letter.
58Test Your Dental Knowledge! Dental Seminar 2010Test Your Dental Knowledge!
59QUIZ TIME!How may copies of the prior approval request should a provider send?a. 5b. 3c. 2 (the original and a copy for the EDS files)c. 2d. 10
60QUIZ TIME!When billing for appliances, what date of service must you use?a. impression dateb. wax try-in datec. delivery datec. delivery dated. approval date
61QUIZ TIME!What field on the ADA form is used for entering quadrant and arch indicators?a. 27 (tooth number or letter)b. 25 (area of oral cavity)b. 25 (area of the oral cavity) is the preferred answerHowever, NC Medicaid does still accept the quadrant or arch indicator in field 27 (tooth number or letter) as stated on page 38 in the dental manual.c. 28 (tooth surface)
62QUIZ TIME! a. PHD b. Oral Surgeon c. 1223G0001X d. 8999999 Which of the following is acceptable data for Field 56A (Provider Specialty Code) on the ADA form?a. PHDb. Oral Surgeonc. 1223G0001X (taxonomy code)c. 1223G0001Xd
64Obtaining prior approval does not guarantee payment. True or False?Obtaining prior approval does not guarantee payment.TRUETRUE
65True or False?Effective with date of service November 1, 2009, sealants on premolars are no longer covered.TRUETRUE
66True or False?The Billing Provider number is required in Field 52A for prior approval requests only.TRUETRUE
67Valplast partial dentures are not covered by NC Medicaid. True or False?Valplast partial dentures are not covered by NC Medicaid.TRUETRUE
68True or False?Unilateral (D1510) and bilateral (D1515) space maintainers should be billed using the tooth number(s) it replaces.FALSED1510 requires quadrant indicators UR, UL, LL, LRD1515 requires arch indicators UP, LOFALSE
69True or False?Providers must furnish a copy of treatment records when requested by any authorized Medicaid representative (i.e. DMA or HP).TRUETRUE
70Top 5 Claim Denials from Dental Providers And How to Avoid Them
71EOB 191Explanation: Recipient Name does not match Medicaid Identification NumberResolution: Verify name of recipient by checking Eligibility Verification System, calling EDS Provider Services or checking MID card
72EOB 143 Explanation: Medicaid ID number not on state eligibility file Resolution: Verify name of recipient by checking Eligibility Verification System, calling EDS Provider Services or checking MID card
73Unknown NPIExplanation: Provider submits an NPI that NC Medicaid does not have on fileResolution: Verify NPI on NPI and Address Database
74EOB 8326 Explanation: Attending Provider ID is missing or unresolved Resolution: Submit an NPI in both billing and attending fields on claim
75Dental Seminar 2010 Contacting Medicaid We’ll wrap up this seminar by providing you with contact information at DMA and EDS.
76Where do I send my…? Prior Approvals HP PO Box 31188 Raleigh, NC 27622 Claims (paper) or RefundsHPPO BoxRaleigh, NC 27622Addresses to send in your PA requests, claims, refunds and paper adjustments – also on the back of your agenda.AdjustmentsHPPO BoxRaleigh, NC 27622
77I want a visit… who do I call? Marianne Diana – Provider RepresentativeDebbie LeBlanc – Provider RepresentativeECS Representatives – billing electronicallyAlvis Tinnin – Eastern countiesSandy Baglio – Western countiesTo get a live human being out to your office for a face to face visit, call the number you see on that agenda page.orOption 3
78Contacting HP Call 1-800-723-4337 Call 1-800-688-6696 or 919-851-8888 Automated Voice Response SystemCall orPress “1” – Electronic Commerce ServicesPress “2” – Prior ApprovalPress “3” – Provider ServicesPress “0” – OperatorAnd here is contact information over the phone for both the AVRS and a human.
79Contacting DMA Recipient Eligibility-within 12 months Eligibility Verification ToolAVRS –Recipient Eligibility-over 12 monthsDMA Claims Analysis –Questions about coverage policyDMA Dental Program –Contacting DMA about recipient eligibility or about dental program coverage policies are also printed on the back.