An Educational Presentation Presented by: Avesis September 2012 Prepared For: Avesis/Wellcare of Kentucky Dental Providers & Staff

Kentucky Dental Mission Statement Building long term partnerships to deliver valued, innovative healthcare solutions… one member at a time.

Kentucky Dental 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

Kentucky Dental Avesis Dental  Dental Networks  Over 30,000 dentists in 41 States  Experienced Administrator  30 years serving corporate and government clients  Avesis administers Medicaid dental plans in 4 states and Medicare Advantage dental plans in 11 states

Kentucky Dental Avesis is National  Executive Offices in Baltimore, MD  Operations located in Phoenix, AZ  Southeast regional office in Atlanta, GA

Kentucky Dental Points of Contact  Renee Ruggiero Assistant Director of Health Plan Services (800) x753  Emori Campbell Dental Provider Relations (800) x178  Carolyn Wright Utilization Management (800) x294

Kentucky Dental Points of Contact  Robin Mays Manager, Dental Provider Contracting (800) x136  Angela Bridges Provider Contracting Specialist (800) x156  General Provider Inquiries (855)

Kentucky Dental Clinical Professionals  Dr. Fred Sharpe Chief Dental Officer  Dr. Rick Celko Regional Dental Director  Dr. Terrence Poole Avesis KY/OH Dental Director

Kentucky Dental Avesis Dental Advisory Board  Committee of Kentucky licensed Dentists and Avesis staff  Acts in an advisory capacity to Wellcare of Kentucky and Avesis in all matters pertaining to the Avesis/Wellcare of Kentucky Dental Programs

Kentucky Dental Avesis Dental Advisory Board  Help to ensure quality communications between Kentucky provider community, Avesis, and Wellcare of Kentucky  Forum for providers to submit recommendations and feedback regarding the programs and their administration

Kentucky Dental Eligibility

Kentucky Dental 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: actual payment is based on the terms and conditions of the plan in force once the claim is received.

Kentucky Dental Eligibility You may obtain eligibility verification four ways: 1.IVR – Please bear in mind that this only provides you with information as to whether or not the member is eligible on the date of service. It does not provide utilization data 2.Website – This method provides you with information as to whether or not the member is eligible on the date of service and allow you to view the members utilization history. ( or check the state website 3.Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data. You may call to reach the Customer service department. 4.Fax – You may utilize the form found of the following slide for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.

Kentucky Dental Fax Eligibility Verification

Kentucky Dental Benefits

Kentucky Dental Benefits Overview  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

Kentucky Dental Benefits Overview  There are two Medicaid programs under Wellcare of Kentucky: Global Choices Family Choice  Benefits for children (Members ages 20 and under) are the same in each of the plans  Benefits for adults (Members ages 21 and over) vary according to the program in which the Member is enrolled.

Kentucky Dental The Global Choices Program Global Choices is the benefit plan for most Kentucky Medicaid members. This plan covers basic medical and dental services. There are no co-pays for any dental services for Wellcare of Kentucky members enrolled in Global choices. Some service limits can be increased if the service is medically necessary (requires prior approval).

Kentucky Dental Benefits for Global Choices  Global Choices benefits include but are not limited to: Children under 21: 2 cleanings per 12-month period 1 set of x-rays per 12-month period Extractions and fillings Other dental services are available Adults 21 and over: 1 cleaning per 12-month period Limited to one dental visit per month 1 set of x-rays per 12-month period Extractions and fillings

Kentucky Dental The Family Choices Program Family Choices is the Kentucky Medicaid benefit plan for most children. This plan covers basic medical and dental services. Kentucky Children’s Health Insurance Program (KCHIP) is part of the Family Choices Plan. This is not a complete list of services. Some benefit limits can be increased if the service is medically necessary (requires prior approval).

Kentucky Dental Benefits for Family Choices  Family Choices benefits include but are not limited to: Children under 21: 2 cleanings per 12-month period 1 set of x-rays per 12-month period Extractions and fillings Other dental services are available

Kentucky Dental General Benefits  Benefit Exception/EPSDT Process Benefit 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 Wellcare of Kentucky for medical benefits

Kentucky Dental Non-Covered Services Disclosure Form This form is for your protection and the Member pays Usual and Customary Fees

Kentucky Dental Claims

Kentucky Dental Claim Submission Claims may be submitted one of three ways:  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 – 7777  Utilizing our website at

Kentucky Dental 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: You may check claim status on the Avesis website at You may contact our provider services department at (855) to check claim status

Kentucky Dental Corrected Claims Submission If you are missing information (i.e. tooth number or quadrant number) or you have submitted incorrect information (wrong code, wrong tooth number, etc.) you may edit the claim on the Avesis website regardless of the method of submission. If you wish to submit a corrected claim on an ADA claim form you will need to do the following: 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

Kentucky Dental Avesis Claims Payment  Check runs weekly  CLEAN CLAIMS processed and adjudicated within 15 business days  Electronic Funds Transfer available for all claims submissions or resubmissions  EFT payments deposited weekly

Kentucky Dental Electronic Funds Transfer Agreement

Kentucky Dental Prior Authorization Pre-treatment Estimates & Benefit Exceptions

Kentucky Dental Avesis Prior Approval Requirements  Services requiring prior approval are listed in detail in the provider manual and on the covered benefits schedule.  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.

Kentucky Dental Chart Reviews

Kentucky Dental Avesis Office Visits  Avesis conducts office reviews for our dental provider networks  Your office will be contacted in order for Avesis to schedule a time to come out  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

Kentucky Dental Provider Services

Kentucky Dental Services to Providers  Avesis is primary for Member and Provider Services  Toll free phones staffed by experienced and knowledgeable representatives from 7am – 7pm EST at  State and National professionals involved in professional decisions regarding care and referrals  Regional meetings and training sessions scheduled for providers  Quarterly Provider Newsletters  On-site assistance in your office when available  Peer to peer interaction for Providers

Kentucky Dental Additional Assistance  Schedule a conference call  Schedule a web demo  Schedule an onsite visit

Kentucky Dental Committed to Technology 24/7 Access to information:  Web Based Eligibility verification Claim submission with real time claims processing Claim status and editing Remittance advice information Pre-treatment Estimate  Interactive Voice Response (IVR) Eligibility Benefits

Kentucky Dental Thank You For Your Time Questions? We at Avesis look forward to working with you and your team.