Presentation on theme: "June 2014 Prepared For: Health Partners Plans Dental Providers and Staff Presented by Avesis."— Presentation transcript:
June 2014 Prepared For: Health Partners Plans Dental Providers and Staff Presented by Avesis
Mission Statement Building long term partnerships to deliver valued, Innovative healthcare solutions... one member at a time 2
Who We Are Dental, Vision, and Hearing Plan Administrator working with employer groups and health plans nationally Over 30 years experience in the dental, vision, and hearing insurance industry Covering over 4.5 million members throughout the country 3
Dental Networks Over 30,000 dentists in 41 States Experienced Administrator 31 years serving corporate and government clients Avesis administers Medicaid dental plans in 4 states and Medicare Advantage dental plans in 18 states Avesis Dental 4
Avesis is National Executive Offices in Owings Mills (Baltimore area), MD Operations located in Phoenix, AZ Southeast regional office in Atlanta, GA Local Provider Representatives serving all of Pennsylvania 5
Points of Contact Dora Wilson Executive Vice President of Health Plan Services (800) x11794 Renee Ruggiero Assistant Director of Health Plan Services (800) x11753 Shauntrai Jones Utilization Management (800) x
Points of Contact cont’d Kelley Owens Health Partners Plans Dental Provider Relations, Eastern PA (800) x11738 Lori Retort Dental Provider Relations, Team Lead (800) x
Points of Contact cont’d Robin Mays Manager, Dental Provider Contracting (800) x11136 Angela Rawlings Provider Contracting Specialist (800) x11291 Lanae Wilson Provider Contracting Specialist (800) x12335 General Provider (866)
10 Avesis Dental Advisory Board Committee of Pennsylvania licensed Dentists: Dr. Mark Goldstein, Dr. Michelle Hudson, Dr. Keith Libou and Avesis Staff. Acts in an advisory capacity to Health Partners Plans and Avesis in all matters pertaining to the Dental Program. Helps to ensure quality communications between Pennsylvania provider community, Avesis and Health Partners Plans. Forum for providers to submit recommendations and feedback regarding the programs and their administration.
11 Cultural Competency As a company dedicated to providing clients with superior service, Avesis fully recognizes the importance of serving Members in a culturally and linguistically appropriate manner. We know from direct experience that: Some Members have limited proficiency with the English language including some Members whose native language is English but who are not fully literate. Some Members have disabilities and/or cognitive impairments that impede their communicating with us and using health care services. Some Members come from other cultures that view health-related behaviors and health care differently than the dominant culture.
12 Cultural Competency cont’d To be culturally competent, Providers shall: Work with Members so that once Members are identified that may have cultural or linguistic barriers alternative communication methods can be made available. Utilize culturally sensitive and appropriate educational materials based on the Member’s race, ethnicity and primary language spoken. Ensure that resources are available to overcome the language barriers and communication barriers that exist in the Member population. Make certain that you recognize the culturally diverse needs of the population. Teach staff to value the diversity of both their co-workers inside the organization and the population served, and to behave accordingly.
13 Special Needs Avesis works in coordination with the Special Needs Unit at the Health Plan to ensure that the dental needs of every Member are met. If you have a Special Needs Member that requires help in securing dental treatment, Avesis can assist in coordinating an appropriate referral to a dental Provider who is able to meet the Member’s specific needs.
15 Eligibility You may obtain eligibility verification three ways: 1.Website – This method provides you with information as to whether or not the member is eligible in our system on the date of service and allows you to view the members utilization history. (www.Avesis.com or check the state website 2.Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data. You may call (866) to reach the Customer Service department. 3.Fax – You may utilize the form found in the Provider Manual and on the secure login for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.
16 Fax Eligibility Verification
17 Eligibility It is strongly encouraged that you verify eligibility for each Member’s appointment the business day prior to rendering services unless the next business day is the first day of a new month. Please note that verification of benefits or eligibility is not a guarantee of payment. If a member is retro termed, a screenshot on the date of service of the member’s eligibility from the state website are permitted for payment.
18 Health Partners Plans
19 Health Partners Plans Health Partners Plans Include: Health Partners - the program for Medical Assistance Members KidzPartners - the program for Pennsylvania CHIP members Health Partners Medicare PrimePlus - a program for Medicare Advantage Members Health Partners Medicare Special- a program for Medicare Advantage Members Benefits vary according to the program in which the Member is enrolled
20 Health Partners Plans cont’d Health Partners Plans offers dental care to eligible Medical Assistance recipients in the Health Partners Plans service area. KidzPartners is available through a contract with the Children’s Health Insurance Program (CHIP) of Pennsylvania. CHIP is a State and Federally funded program to provide health insurance for uninsured children from birth until they reach the age of 19. In 2007, Pennsylvania CHIP was expanded to offer health insurance to children and teens who are not eligible for Medical Assistance, regardless of family income. Enrollment eligibility is evaluated every 12 months. Health Partners Medicare PrimePlus offers choices for more enhanced dental services and care options that are available through traditional Medicare including routine dental services. Health Partners Medicare Special offers choices for more enhanced dental services and care options that are available through traditional Medicare including routine dental services.
21 Health Partners Plans Benefits
22 Benefits and Fee Reimbursements Benefits and Fee Schedules for Health Partners Plans can be found on the Avesis portal: After logging in, to the right, click on Related Documents. You are then able to view, print or download a copy of the Benefit Grids, Fee Schedules and Provider Manual.
23 Program Exception Program Exception Process A program exception occurs when a provider contacts Avesis requesting services that are non-covered for medical necessity. Benefits are either exhausted or not a covered benefit. Requests will be reviewed by Utilization Management and a decision will be made with in two (2) business days. Emergency Services Members seeking emergency services may need to be referred back to Health Partners Plans for medical benefits.
24 Program Exception Process Program Exception Process (Members under 21) The program exception process occurs when a provider requests review of a service that is not a covered benefit to determine if an exception should be made based on medical necessity. Key Principles The KidzPartners product benefit plan does not provide any provision for program exceptions. Health Partners Plans’ Medical Assistance program requires consideration of written provider requests for a program exception if the member is 20 years of age or younger. For members greater than 20 years of age, only specific services may be reviewed by Avesis for a benefit exception (see benefit limit exceptions for members over 21).
25 Program Exception Process cont’d Process: If a Health Partners Plans’ Medical Assistance member or provider contacts Avesis and requests coverage of a non-covered item or service or a “program exception,” the following procedure should be followed: 1.Requests for program exceptions must delineate the medical necessity for the exception via a Letter of Medical Necessity from an Avesis provider or a Health Plan physician. 2. Letters of Medical Necessity must be forwarded to the attention of “Avesis Utilization Management-Benefit Exception” via fax # (866) ” 3. Requests will be reviewed for medical necessity and appropriateness. 4. Avesis must make a determination and notify the provider and member verbally within two (2) business days of receipt if all of the information needed to make the determination is available. Written notification must be sent within two (2) business days of the verbal notification to the Provider and Member. If all of the information is not available, additional information must be requested within two (2) business days. If we do not receive the additional information within 14 days, the decision to approve or deny the service will be made, based on the available information.
26 Benefit Limit Exception Benefit Limit Exception Process: Effective April 1, 2012, Health Partners Plans’ adult members (age 21 and older) will be eligible for the following services only if Avesis approves a BLE request: Crowns and adjunctive services (D2710, D2721, D2740, D2751, D2791, D2910, D2915, D2920, D2952, D2954, D2980) Periodontic services (D4210, D4341, D4355, D4910) Endodontic services (D3310, D3320, D3330, D3410, D3421, D3425, D3426) NOTE: The dental benefit changes do not apply to children under 21 years of age or to adults who reside in a nursing facility, an intermediate care facility for persons with mental retardation (IFC/MR) or an intermediate care facility for persons with other related conditions (IFC/ORC) Requests will be reviewed by Utilization Management and a decision will be made within twenty one (21) business days.
27 Health Partners Limited Plan Also beginning on January 1, 2012, members with limited dental benefits (who are 21 years of age and older and do not reside in a nursing home or intermediate care facility) will only be eligible for the following services: Palliative care, (the emergency treatment of dental pain). Dental Care provided in a Short Procedure Unit (SPU), Ambulatory Surgical Center (ASC) or Inpatient Hospital. The following dental care may be covered: 1. Oral surgery and impacted teeth removal if the nature of the procedure or the member’s compromising condition would cause undue risk if performed on an Outpatient basis; or 2. Teeth extraction and dental restorative services for a member who is unmanageable and requires general anesthesia by an anesthesiologist, not the dentist, due to a severe mental and/or physical condition.
28 Covered and Non-Covered Covered Services Covered services will be paid according to the plan fee schedule. Non-Covered Services Non-Covered Services may be the responsibility of the member if and only if the Member is notified of and agrees to financial responsibility prior to services being rendered.
29 Non-Covered Disclosure Form A member receiving a non-covered Service must sign and date a disclosure form prior to rendering treatment and must include the date of service, procedure code, description of service and fee. The chargeable fee is: The fee listed on the Fee Reimbursement Schedule or 20% under the Provider’s Usual and Customary fee if the code is not listed on the Fee Reimbursement Schedule.
31 Claims Submission Claims may be submitted one of three ways: 1.Through your practice management software using a clearinghouse The Avesis payer identification number is On an ADA claim form - please submit to the following address: Avesis Dental Claims PO Box 7777 Phoenix, AZ – Utilizing our website at
32 Claims Follow-Up Providers receive remittance advices detailing claims both paid and denied. If you believe you have not received status on a claim, you may check the status of submitted claims two ways: 1.You may check claim status on the Avesis website at 2.You may contact our Customer Service department at (866) to check claim status
33 Corrected Claims Submission If you are missing information (i.e. tooth number or area) or you have submitted incorrect information (wrong code, wrong tooth number, etc.) you may edit the ADA claim form and send marked as ‘corrected’ with the claim number, if a claim number has been assigned, to the Phoenix, Az office. Write Corrected Claim on the top of the ADA claim form in blue or black ink. The scanner does not read red ink Please do not highlight notes on the claim in blue or green highlighter. The scanner reads these colors as black so what ever they highlight is blacked out
34 Appeals Provider Appeal Process for Denial of Claim(s) Procedure Levels: Administrative-involves adverse determination for reasons other than medical necessity (e.g. timeliness of filing, no prior authorization, etc.) Medically Necessary Appeals-involves adverse determination finding that there was no medically necessary reason to pay the claim. a.Written request stating that it is an appeal within thirty (30) days of denial. b.Address to the Phoenix office; clearly mark the envelope Attn: Appeals c.Appeal decision is determined and provider notified if upheld or paid if the initial determination is reversed and to be paid out.
35 Avesis Claims Payment Check runs are weekly Electronic Funds Transfer (EFT) payments deposited weekly Card Payment Services (CPS) transactions completed weekly CLEAN CLAIMS are processed and adjudicated within 15 business days. State guidelines are within 30 days
36 Electronic Funds Transfer Agreement
37 Prior Authorization
38 Avesis Prior Approval Requirements Services requiring prior approval are listed in detail on the covered benefits schedule and describe the required attachments. Providers may submit pre-treatment estimates on an ADA claim form to our Phoenix address or via the Avesis website at Avesis accepts electronic attachments via the Avesis web portal or through NEA (National Electronic Attachment)
39 EPSDT Early and Periodic Screening, Diagnostic and Treatment
40 EPSDT Defined The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, clinical, dental, mental health, and developmental and specialty services. In December 2010, the Centers for Medicare and Medicaid Services (CMS) convened a Workgroup that includes state representatives, children’s health providers, consumer representatives, and other experts in the areas of maternal and child health, Medicaid, and data analysis. The group helps CMS identify the most critical areas for improvement of EPSDT, and provides ideas on how CMS can work with states and other partners to increase awareness and access to services, and improve data reporting to improve the quality of care provided to children.
41 EPSDT EPSDT includes periodic screening, vision, dental, and hearing services If a Provider is unable to conduct the necessary EPSDT screens for Members under age 21, the Provider is responsible for making a referral to another Participating Provider to ensure the Member has the necessary EPSDT screening performed. All relevant medical information, including the results of the EPSDT screening, are to be incorporated into the Member’s primary medical record. Based upon the requirements of the EPSDT program, each Avesis Provider office is required to maintain and document the Member recall policies and procedures for all Health Partners and Kidz Partners members. Additional information on the EPSDT program can be found at
42 Chart Reviews
43 Avesis conducts office reviews for our dental provider networks Your office will be contacted in order for Avesis to schedule a time to visit In addition to a facility walk through, providers will be furnished a list of charts prior to the visit to have available for review After the visit, your office will be sent a letter regarding the findings of our review Avesis Office Reviews
44 Avesis Facility Review 1-ACCESS Street Signage Parking Handicapped Entry Entry Signage 2-WAITING AREA Number of Seats Magazines, TV / Video Game Area Sufficient Size 3-RECEPTION AREA Access Greeting Manuals Sufficient Size 4-STAFF 5-TREATMENT AREAS Number of Ops DDS / Hygiene License displayed Lab on Site Clean & Neat 6-X-RAY MACHINES Number of PA Units Panoramic Unit Inspection Date Exam prior to X-ray Lead Apron Darkroom Badges Daylight Developer 7-STERILIZATION Sterilizers Steam/Chemical Cold Sterilization Meets OSHA rules 8-INFECTION CONTROL Gloves worn Masks worn Scrubs worn Hand washing Water line flushing Sharps Containers Spore Testing Anti-back Flow Valves Barrier Techniques 9-MISCELLANEOUS Nitrous Available Fire Extinguishers CPR Training Emergency Training Emergency Kit Medicines Up to Date AED Equipment
45 Avesis Chart Review Individual Chart per Patient HIPAA Statement Medical History Signed & dated by dr or staff Signed & dated by member Reviewed within 1 year Allergies Noted Medications Reviewed Physician Listed Medical Alerts Obvious Radiographs Mounted & Dated Patient Record Missing teeth Caries &/or current restorations Treatment Plan Signed authorization for tx Referrals to specialists Prescriptions given Chart Documentation Quality of Care - Standard of Care Tooth # billed matches chart Codes billed matches chart DOS billed matches chart Billing DDS matches Tx billed supported by documentation Tx appears appropriate X-rays taken support treatment Recall System Frequency
46 Provider Services
47 Services to Providers Avesis is primary for Provider Services Toll free phones staffed by experienced and knowledgeable representatives from 7am – 7pm EST at State and National professionals are involved in professional decisions regarding care and referrals Regional meetings and training sessions are scheduled for providers Quarterly Provider Newsletters are sent On-site assistance in your office is scheduled, according to availability Peer to peer interaction is available for Providers
48 Additional Assistance Schedule a conference call Schedule a web demo Schedule an onsite visit
49 Committed to Technology 24/7 Access to information: Web Based o Eligibility verification o Claim submission with real time claims processing o Claim status and editing o Remittance advice information o Pre-treatment Estimate o On line training and education materials at Interactive Voice Response (IVR) o Eligibility o Benefits
50 Thank You For Your Time! Questions? We at Avesis look forward to working with you and your team.