1. Online Claim Entry Dental Billing
Conduent Government Healthcare Solutions

2. Resources New Mexico Web Portal Provider Information section
When online use: Ask Service Representative
Call Center or
New Mexico Web Portal
Provider Information section
Links and FAQ section
Provider Login section
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3. Important State Websites - Dental
Dental Program Policy:
Dental Provider Billing Instructions:
Registers and Supplements:
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4. Important State Websites - Dental
Dental Fee Schedule:
Providers can find a copy of a HLD Index Scoring Sheet, at the link below:
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5. The Billing Process
Conduent Government Healthcare Solutions

6. Before You Bill Medicaid
Check the recipient’s eligibility for Medicaid.
Check the recipient’s eligibility for dental services.
Check the recipient’s service limits.
Check the procedure code on the dental fee schedule to determine if prior authorization is needed.
Check for other dental insurance coverage.
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7. Before You Bill Medicaid
Check the procedure code on the fee schedule to see if New Mexico Medicaid covers that code.
Check the current version of the ADA’s Current Dental Terminology code book for correct procedure codes.
Check to see if the procedure code requires tooth, surface, or quadrant indicators.
Check to see if co-payment is required.
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8. Ways to Check Eligibility
On-Line Eligibility Inquiry—Web Portal
Automatic Voice Response System (AVRS) (800)
Conduent Eligibility Help Desk: (800)
Monday - Thursday 8:00 a.m. - 5:00 p.m.
Friday (Mountain Time) 8:00 a.m. - 4:00 p.m.
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9. Eligibility Inquiry
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10. Eligibility Details
What do I do if I receive a denial pertaining to the recipient’s eligibility?
Verify recipient eligibility for the date of service on the Web Portal.
Verify correct patient ID, DOB and Name.
Attach an authorization (CMS 309), if CMS recipient.
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11. Dental Services Are Not Covered Under These Categories:
029 – Family Planning
035 – Pregnancy Related (NAX) when patient is exempt from a SALUD plan
035 (2) – Premium Assistance for Maternity (PAM)
041, 044 – Qualified Medicare Beneficiary (QMB)
062, 063 – State Coverage Insurance (SCI)
072 (2) – Premium assistance for Kids (PAK)
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12. Categories of Eligibility with Co-pays
Recipients the COE’s below may require co-pays for some services.
071 – CHIP (Children’s Health Insurance Program)
074 – WDI (Working Disabled Individuals)
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13. CHIP Co-Payment Schedule
Service
Co-payment
Outpatient Physician Visit
Urgent Care Visit
Outpatient Therapy Visit
Other Practitioner Visit Dental Office Visit
$5.00
$ co-pay does not apply if service is preventative, diagnostic, or orthodontic.
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14. WORKING DISABLED INDIVIDUAL (WDI) CO-PAY AMOUNTS
$7.00 outpatient therapy and behavioral health services
$20.00 emergency room services
$30.00 inpatient hospital services.
$7.00 doctor visit, urgent care or vision visit
$7.00 dentist visit
$5.00 prescriptions
Please Note: Native Americans are exempt from CHIP and WDI co-payment requirements.
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15. CMS (Children’s Medical Services) Claims Submission
CMS is the same as billing for a Medicaid recipient with the following differences:
Always use the 14 digit CMS recipient ID number that begins with 07.
Always enter the PA number in box 2 of the ADA form (if the PA number is 8 digits, add 2 zeroes in front of it).
When submitting on paper, always attach the 309 form or copy of the Healthier Kids card.
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16. Utilization Review (UR)
CMS is the same as billing for a Medicaid recipient with the following differences:
Always use the 14 digit CMS recipient ID number that begins with 07.
Always enter the PA number in box 2 of the ADA form (if the PA number is 8 digits, add 2 zeroes in front of it).
When submitting on paper, always attach the 309 form or copy of the Healthier Kids card.
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17. Prior Authorization Requirements
Services requiring a PA include but are not limited to the following:
Children’s benefits: Periodontics, braces, crowns, crown repair, root canals, maxillofacial prosthetics, certain maxillofacial repair services.
Adult benefits: Periodontics, dentures/partials and root canals (front teeth only), maxillofacial prosthetics, certain maxillofacial repair services.
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18. Prior Authorization Requirements Fee for Service (FFS)
Important Information for Fee for Service Dental Services:
Prior authorization (PA) requests for dental services for FFS Medicaid recipients must be submitted to DentaQuest at the address listed below.
PA requests are submitted on the ADA form (appropriate ADA codes and tooth numbers/quadrants must be indicated) with appropriate documentation and clinical material, such as x-rays, charting, and study models for orthodontia. 
DentaQuest
12121 North Corporate Parkway
Mequon, WI 53092
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19. Prior Authorization Requirements Fee for Service (FFS)
Indicate Prior Authorization at the top of the ADA form.
Do not list Date of service.
If date of service or no indication is made at  the top or the form, the form maybe mistaken for a dental claim submission.
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20. Prior Authorization Requirements Fee for Service (FFS)
Recommended Steps for Provider Inquiries Regarding the Status of a FFS Dental Prior Authorization:
Check the New Mexico Medicaid Web Portal and confirm the PA numbers.
If there is no PA on the web portal, contact DentaQuest at (800) for the status.
If you have contacted DentaQuest for a status check and are not able to view the PA on the Conduent web portal, or more information is needed on the PA, contact Molina Healthcare Third Party Assessor Dental Care Coordinator toll-free at (800) , ext or in Albuquerque at (505) to resolve the issue
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21. Prior Authorization Requirements Fee for Service (FFS)
Recommended Steps for Provider Inquiries Regarding the Status of a FFS Dental Prior Authorization (Continued):
4. If you have questions about a dental claim denial, contact the Conduent provider Relations Helpdesk at
5. If after you have followed steps 1-4 (above) and issues are still unresolved, please contact Medical Assistance Division Staff Manager, Devi Gajapathi at (505)
6. If you have recipients that have questions regarding PA status, please refer them to Molina Healthcare Dental Care Coordinator, Christopher Salazar at (505)
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22. Orthodontic Authorizations
To ensure your orthodontic authorizations are processed efficiently and timely, we would like to remind you of the appropriate way to submit orthodontic authorization requests. Per New Mexico Medical Assistance Division Utilization Review instructions UR Dental Services:
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23. Orthodontic Authorizations
The documentation required must include each of the following:
Diagnostic Casts or digital study models 
Full mouth or panoramic x-ray
Cephalometric film 
Diagnostic Photographs
A completed orthodontic screening form that states the Handicapping Labiolingual Deviation Index (HLD) score and indicates the handicapping malocclusion. The provider may submit either the original or a copy.
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24. Orthodontic Authorizations
Prior to making a decision, DentaQuest may issue a request for information (RFI) to the provider requesting clarification or additional information, in order to have sufficient information to render an appropriate decision.
The provider must submit the clarification or additional information within 21 calendar days of issuance of the request or a technical denial may be issued ( NMAC).
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25. Orthodontic Authorizations
If your office needs the models, returned please include a postage paid container, appropriate to securely return the ortho models or a postage paid label that we can apply to a container that we have available.
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26. Orthodontic Authorizations
As a reminder, you can receive 24 hour service 7 days a week by using to check member eligibility, history, submit claims, authorizations and many other features. 
Should you need other assistance, or wish to use our interactive voice response system, please contact DentaQuest at
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27. Procedure Codes and Fee Schedule
Procedures must be reported using the American Dental Association’s dental procedure codes and terminology. For complete code descriptions, terms and definitions, reference the Current Dental Terminology manual.
NM Medicaid Dental Fee Schedule is available:
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28. Procedure Codes and Fee Schedule
Dental services must be billed with a “D” and a four digit code.
Oral cavity designations for quadrants are as follows:
10 – UR
20 – UL
30 – LL
40 - LR
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29. Service Limits – Children’s Services
Certain services are limited in frequency:
Two dental exams per year
Two cleanings every six months
Two fluoride treatments per year
Sealants:
Not covered on pre-molars
Only pay for sealants once every five years
O – Occlusal is the only surface covered
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30. Service Limits – Adult Services
Certain services are limited in frequency:
One dental exam per year
One cleaning per year
Adults are not eligible for braces or crowns.
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31. Service Limits – Dentures and Partials
Dentures and partials require PA
Payment include 2 adjustments during the first 6 months after delivery.
Adjustments are limited to 2 per year.
Repairs are limited to 2 per year for full and partial dentures.
Relining dentures is limited to once every 3 years.
Relining cannot be billed during the six months following the insertion of the prosthesis.
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32. Service Limits – X-Rays
Full mouth or panoramic x-rays are covered once every 3 years.
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33. ADA Claim Form Requirements
Conduent Government Healthcare Solutions

34. Electronic Claim Submission
All Fee For Service claims within 90 days from the initial date of service that do not require an attachment for payment must be submitted electronically.
For any assistance regarding Electronic Claims Submissions, contact the HIPAA Helpdesk
  or call
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35. Timely Filing Denials Exceptions to the filing limit:
When the provider was not originally enrolled as a MAD provider on the date of service, the filing limit of 90 days is counted from the date the provider was notified of their enrollment, but must not exceed 210 days from the date of service. A provider should submit a provider participation agreement in sufficient time to allow processing and still meet the Medicaid 210 day limit for submitting the claim.
When a claim previously paid by a Medicaid managed care organization is recouped from a provider due to retroactive disenrollment of the recipient from the managed care organization, the filing limit of 90 days is counted from the date of the managed care organization’s notice or recoupment from the provider.
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36. Re-filing Claims and Submitting Adjustments
Timely Filing Denials
Re-filing Claims and Submitting Adjustments
When resubmitting a claim or requesting an adjustment on a claim that is past the 90 day filing limit but originally met the filing limit, the “TCN” number which appears on the remittance advice (RA) will be used by Conduent to evaluate the claim. The provider must supply that TCN number in order for Conduent to be able to evaluate the claim.
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37. Re-filing Claims and Submitting Adjustments
Timely Filing Denials
Re-filing Claims and Submitting Adjustments
Online Claim Entry ADA Dental Claim Form:
Enter the TCN number in “Timely Filing TCN” field
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38. ADA 2006 Dental Online Claims Entry
Conduent Government Healthcare Solutions

39. ADA 2006 Claim Submission
Use procedure codes that are specific to your claims.
You can get a copy of the ADA 2006 Claim form instructions for Medicaid requirements.
This will give you box by box information on how to fill out the claim form for Medicaid primary, TPL primary, or HMO/PPO primary claim variations.
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40. Where Do I Get a Copy of Claim Form Instructions?
On the WEB PORTAL: Click Providers then Forms, Publications, and Instructions under Provider Information
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41. Where Do I Get a Copy of Claim Form Instructions?
Scroll down
Make titles consistent – capital letters
Open file
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42. ADA Dental Online Claims Entry
Make titles consistent – capital letters
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43. ADA Dental- Primary Example
Make titles consistent – capital letters
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44. ADA Dental- Primary Example
Make titles consistent – capital letters
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45. ADA Dental- Primary Example Claim Information
Make titles consistent – capital letters
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46. ADA Dental- Primary Example Attachments
Make titles consistent – capital letters
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47. ADA Dental- Primary Example Line Item Information
Make titles consistent – capital letters
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48. ADA Dental- Primary Example
Make titles consistent – capital letters
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49. TPL Billing Instructions
Indicate “Other insurance” in the “Other Insurance Info” section of claim.
Attach a copy of the EOB from the other insurance. Always attach the list of EOB code explanations from the other carrier.
Prior Payment Amount field needs to be filled in with the paid amount from the primary payer.
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50. TPL Example
Make titles consistent – capital letters
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51. TPL Example
Make titles consistent – capital letters
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52. Co-pay Billing Instructions
Indicate PPO\HMO in the “Other Insurance Info” section of claim.
The NM Medicaid program requires a prior payment made by a primary payer to be entered in the “Prior Payment Amount” field.
If trying to collect a flat co-payment amount, the amount entered in the “Prior Payment Amount” should be the difference between the total billed and the co-payment amount.
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53. Co-pay Billing Instructions
Leave blank if there is not a primary payer or if the primary payer did not make a payment on the claim.
*Note: Do not enter previous amounts paid by Medicaid on these services.
Claims partially paid by Medicaid need to be submitted as adjustments when trying to collect for the unpaid or partially paid services on the claim.
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54. Co-pay Billing Instructions
Make titles consistent – capital letters
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55. Co-pay Example
Make titles consistent – capital letters
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56. Billing Instructions- Reminders
Rendering NPI number is always required!
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57. Conduent Field Representatives
Provider Field Representative:
Robert Gipson – (505) Ext
Cc:
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58. Contact Us HIPAA.Desk.NM@Conduent.com NMProviderSupport@Conduent.com
Call Center or
New Mexico Web Portal
Provider Information section
Links and FAQ section
Provider Login section
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