Texas Provider Best Practices 2013 – Medicaid and CHIP

2 Agenda  Understanding the Office Reference Manual (ORM)  Most Common Denial Reasons and Codes  Definition of Medical Necessity  Clinical Criteria  CHIP – Exceeding $564 Benefit Max  Narratives  X-rays / Photos  Appeals Process  Questions

3 Office Reference Manual (ORM)… The Office Reference Manual (ORM) is located on the portal and on under Provider Information. Let’s take a tour!

4 Most Common Denial Reasons… Clinical 1. CHIP – No narrative or supporting documentation for exceeding the $564 maximum. 2. Extractions – Submitting for a higher code than documentation supports. For example, D7240 for a soft tissue impaction 3. Crown – Tooth does not have extensive decay on multiple surfaces or moderate cuspal involvement. 4. Crown – No pre-op radiograph provided. Pre-op and post-op radiographs are required. 5. Third molar extractions – Provider does not submit a tooth specific narrative, the notes are generic or a template used for every prior auth.

Denial Reasons (cont’d)… Administrative 1.Service exceeds benefit limitations or maximum benefit allowance. 2. Submitting provider is not the member’s Primary Care Dentist. 3. This procedure is a duplicate of a service previously processed. 4. Patient is not eligible for program. 5. This procedure has been submitted after the timely filing limit. 5

6 Medical Necessity… Medically necessary is defined in the Texas Administrative Code (TAC) Rule 353.2

Pre-payment Review vs. Prior Authorization Covered dental services that indicate “Yes” in the “Review Required” column will be subject to retrospective pre-payment review. These procedures can be rendered before determination of medical necessity but require submission of proper documentation (as indicated in the “Documentation Required” column) with the claim form that supports medical necessity. As an option, services that indicate “Yes” in the “Review Required” column can also be submitted for prior authorization prior to rendering the services. 7

Clinical Criteria 8

9 Dental Extractions… Documentation needed for pre - payment review or prior authorization:  Appropriate radiographs showing clearly the adjacent and opposing teeth should be submitted for authorization review: periapicals or panorex.  Treatment rendered under emergency conditions, when authorization is not possible, will still require that appropriate radiographs showing clearly the adjacent and opposing teeth be submitted with the claim for review for payment.  Narrative demonstrating medical necessity.

Criteria…  The prophylactic removal of asymptomatic teeth (i.e. third molars) or teeth exhibiting no overt clinical pathology is subject to consultant review.  The removal of primary teeth whose exfoliation is imminent does not meet criteria.  Alveoloplasty (code D7310) in conjunction with four or more extractions in the same quadrant will be covered subject to consultant review. 10

Endodontic… Documentation needed for pre-payment review or prior authorization:  Sufficient and appropriate radiographs showing clearly the adjacent and opposing teeth and a pre-operative radiograph of the tooth to be treated; periapicals or panorex. A dated post-operative radiograph must be submitted for review for payment.  Treatment rendered under emergency conditions, when authorization is not possible, will still require that appropriate radiographs clearly show:  The adjacent and opposing teeth.  Pre-operative radiograph and dated post-operative radiograph of the tooth treated. In cases where pathology is not apparent, a written narrative justifying treatment is required. 11

Criteria… Root canal therapy is performed in order to maintain teeth that have been damaged through trauma or carious exposure. Root canal therapy must meet the following criteria:  Fill should be sufficiently close to the anatomical apex to ensure that an apical seal is achieved.  Fill must be properly condensed/obturated. Filling material does not extend excessively beyond the apex. 12

Authorizations for Root Canal therapy will not meet criteria if:  Gross periapical or periodontal pathosis is demonstrated radiographically (caries subcrestal or to the furcation, deeming the tooth non-restorable).  The general oral condition does not justify root canal therapy due to loss of arch integrity.  Root canal therapy is for third molars, unless they are an abutment for a partial denture.  Tooth does not demonstrate 50% bone support.  Root canal therapy is in anticipation of placement of an overdenture.  A filling material not accepted by the Federal Food and Drug Administration (e.g.Sargenti filling material) is used. 13

Other Considerations…  Root canal therapy for permanent teeth includes diagnosis, extirpation of the pulp, shaping and enlarging the canals, temporary fillings, filling and obturation of root canal(s), and progress radiographs, including a root canal fill radiograph.  In cases where the root canal filling does not meet DentaQuest’s treatment standards, DentaQuest can require the procedure to be redone at no additional cost. Any reimbursement already made for an inadequate service may be recouped after DentaQuest reviews the circumstances. 14

Stainless Steel Crowns… Documentation needed for pre-payment review or prior authorization:  Appropriate radiographs showing clearly the adjacent and opposing teeth should be submitted for authorization review: bitewings, periapicals or panorex.  Treatment rendered under emergency conditions, when authorization is not possible, will still require that appropriate radiographs showing clearly the adjacent and opposing teeth be submitted with the claim for review for payment.  Narrative demonstrating medical necessity if radiographs are not available. 15

Criteria…  In general, criteria for stainless steel crowns will be met only for teeth needing multi-surface restorations where amalgams and other materials have a poor prognosis.  Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma, and should involve four or more surfaces and two or more cusps.  Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma, and should involve three or more surfaces and at least one cusp.  Permanent anterior teeth must have pathologic destruction to the tooth by caries or trauma, and should involve four or more surfaces and at least 50% of the incisal edge.  Primary molars must have pathologic destruction to the tooth by caries or trauma, and should involve two or more surfaces or substantial occlusal decay resulting in an enamel shell. 16

A request for a crown following root canal therapy must meet the following criteria:  Request should include a dated post-endodontic periapical radiograph.  Tooth should be filled sufficiently close to the radiological apex to ensure that an apical seal is achieved.  The filling must be properly condensed/obturated. Filling material does not extend excessively beyond the apex. 17

To meet criteria, a crown must be opposed by a tooth or denture in the opposite arch or be an abutment for a partial denture…  The patient must be free from active and advanced periodontal disease.  The fee for crowns includes the temporary crown that is placed on the prepared tooth and worn while the permanent crown is being fabricated for permanent anterior teeth. Payment for crowns must be billed on seat date and not prep date.  Cast Crowns on permanent teeth are expected to last, at a minimum, five (5) years. 18

Authorizations for Crowns will not meet criteria if:  A lesser means of restoration is possible.  Tooth has subosseous and/or furcation caries.  Tooth has advanced periodontal disease.  Tooth is a primary tooth.  Crowns are being planned to alter vertical dimension. 19

Periodontal Treatment Documentation needed for pre-payment review or prior authorization:  Radiographs – periapicals or bitewings preferred.  Complete periodontal charting with AAP Case Type.  Treatment plan. 20

Criteria…  A minimum of four (4) teeth affected in the quadrant.  Periodontal charting indicating abnormal pocket depths in multiple sites.  Additionally, at least one of the following must be present: 1. Radiographic evidence of root surface calculus. 2. Radiographic evidence of moderate to severe loss of bone support. 21

CHIP… Covered Dental Services are subject to a $564 annual benefit limit unless an exception applies. CHIP Members who have exhausted the $564 annual benefit limit continue to receive the following Covered Dental Services in excess of $564 annual benefit maximum: (1) The preventive services due under the 2009 American Academy of Pediatric Dentistry Periodicity schedule (Volume 32, Issue Number 6 at pp ); and (2) Other Medically Necessary Covered Dental Services approved by the Dental Contractor through a prior authorization process. These services must be necessary to allow a CHIP Member to return to normal, pain and infection-free oral functioning. Documentation to support medical necessity must be submitted with the prior authorization. This includes narrative, x-rays and/or photos when x-rays are not possible. 22

CHIP – Medically Necessary Services… Typically this includes: - Services related to the relief of significant pain or to eliminate acute infection. - Services related to treat traumatic clinical conditions. - Services that allow the CHIP Member to attain the basic human functions (e.g. eating, speech, etc.). - Services that prevent a condition from seriously jeopardizing the CHIP Member’s health/functioning or deteriorating in an imminent timeframe to a more serious and costly dental problem. 23

24 Narratives… Narratives are very important to our Dental Director when making clinical decisions. Many of you have asked the questions, “What is a good narrative?” Every member is unique and a narrative should be submitted to address the member. This means that submitting the same narrative verbatim for multiple members would not be acceptable. While we cannot provide you with specific narratives, we can provide some helpful tips. A good narrative:  The narrative should be tooth specific and describe the symptoms that are being exhibited by the member.  If the member is or has been on antibiotics, this should be included in the narrative.  If the member is or has been on painkillers for an extended period of time, this should be included in the narrative.  If the member’s age could be a determining factor, this should be included in the narrative.  If there is any symptom present that is not identifiable by viewing the x-ray, this should be included in the narrative (such as inflammation or pain beyond normal eruption).

Narrative (cont’d)… A bad narrative:  Does not describe a condition that meets clinical criteria for approval. The example below does not provide enough information to deem teeth as symptomatic.  Impacted 1,16,17,32. Request Removal due to pain  A template or blanket statement that is used for every member.  Recommending extraction for solely preventive reasons. 25

X-Rays We require that x-rays be mounted Claims received with more than four (4) un-mounted x-rays will be returned for mounting. Please make sure the x-rays are of diagnostic quality, properly mounted, dated, marked with left and right, and identified with the member's name. Below are the options in which you can submit x-rays to us. These are (in order of preference): 1. Electronically using either NEA (National Electronic Attachment) or the DentaQuest Provider Web Portal. 2. Mail duplicate x-rays with your ADA form. 3. Send original x-rays, your ADA form, and a self-addressed stamped envelope (SASE) so that we may return the x-rays to you. We are unable to return x-rays received without a SASE. X-rays without a SASE will be scanned and recycled. 26

Appeals… You have 120 days from the date of the EOB to submit an appeal. To submit an appeal, make a copy of the EOB and circle the claims in question. Please note why you are requesting the appeal and provide documentation such as a narrative, photos and X-rays to support medical necessity. If you don’t have the EOB, you can submit the appeal using your office’s letterhead. Please include the following information:  Claim number  Member name, date of birth and member ID  Dentist name, NPI and TPI  Explanation for the appeal  Documentation such as a narrative, photos and X-rays to support medical necessity. In addition, if your office uses NEA, you may submit the NEA number. 27

Appeals (cont’d)… Appeals may be submitted by mail to the following address: DentaQuest-TX HHSC Dental Services Complaints & Grievances Stratum Executive Center Research Blvd Building D, Suite D-400 Austin, TX If the appeal is denied, a peer-to-peer can be requested by contacting the call center at

Appeals (cont’d)… Appeals may also be submitted on the portal using the following steps: Log onto the portal and click on Tools Then, click on Contact DentaQuest 29

Appeals (cont’d)… You will be taken to a Message screen where you will be able to submit information electronically (screenshot on next slide). You can only submit 1 attachment using this process so it is important that you do the following to keep the process as simple as possible. Please make sure the following is provided:  Claim number (search function)  Member name, date of birth and member ID (search function or description box)  Dentist name, NPI and TPI (search function or description box)  Explanation for the appeal  NEA number for x-rays (if available)  If the x-rays are not available via NEA, they can be uploaded as an attachment. If you have multiple attachments, you must zip the file prior to uploading to comply with the 1 attachment rule. 30

Please remember that it is not necessary to submit a copy of the ADA claim form and the EOB if all information regarding the claim is documented in the Description box or search fields and no changes are being made to the original ADA claim form. 31

32 Quick access to provider resources:  Training Schedules and presentations – Provider Information / Training Schedule  Office Reference Manual (ORM), Ortho Policy, Interim Care Transfer From – Provider Information / Important Documents  Provider Newsletters (Texas Roundup) – Provider Information / Provider Newsletters

33 Portal Overview

34 Enter your Username and Password to access the Dentist Home Page

35 Claims/Pre-Authorization Menu Claim/Pre-Authorization Status Search- Use this sub-menu item to search for the status of a claim or pre-authorization. Remittance Advice Search- Use this sub-menu item to view remittance advice statements. Dental Claim Entry – Use this sub-menu to enter and submit dental claims. Dental Pre-Authorization Entry- Use this sub-menu to enter and submit dental pre-authorizations. Dental Claim Confirmation Report- Use this sub-menu to create a dental claims confirmation report. This report will list all claims that have been submitted through the web for that day. The Claims/Pre Authorization menu includes the following menu items:

36 Dental Claim Entry Key 1.Basic Information-Service Date, Group NPI, Service Office, Treating Dentist and POS (Place of Service). 2.Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency, COB,EPSDT, Notes. 3.Member Eligibility-DOB, Member ID, Last Name, First Name. 4.Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt. 5.File Attachments- click Add File to upload an attachment

37 Dental Pre-Auth Entry Key 1. Basic Information-Group NPI, Service Office, Treating Dentist and POS (Place of Service). 2.Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency, EPSDT, Notes. 3.Member Eligibility-DOB, Member ID, Last Name, First Name. 4.Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt. 5. File Attachments- click Add File to upload an attachment

38 Claim/Pre-Authorization Status Search Search Criteria Key: 1. Member Last Name 2. Member First Name 3. Member Number 4. Member DOB 5. Servicing Dentist 6.Claim/Pre-authorization Number 7. Type: Dental Claim or Pre- Authorization 8. Status Category: Successfully Entered, Accepted, In Process, Adjudicated, Finalized 9. Date From/To: Enter the Date of Service 10. Claim Received Date From/To: Enter the Claim or Pre-auth Received Date. This page allows you to conduct a claim or pre-authorization search. **At least one search criteria must be entered to perform a search**

39 Claim/Pre-Authorization Status List This page appears with any claims or pre-authorizations that met your criteria search To download the list, click Download File. To view details on a claim/pre-authorization, click the Claim/Pre-Authorization Number link. To view the member’s details for a claim, click the Member Name link. To view the Dentist Directory Detail page, click the Dentist link for a claim. To perform a new search, click Search Again. To perform a remittance advice search, click RA Search.

40 Questions and Answers