EmblemHealth Provider Training April 17, 2017

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1 EmblemHealth Provider Training April 17, 2017

2 DentaQuest Overview Today DentaQuest is 2 nd Largest Dental Plan 2

3 DentaQuest Overview Offices Massachusetts Wisconsin Florida Texas Tennessee South Carolina California Serving 24 Million Lives! 3

4 New York Provider Engagement Representative Territory Assignments l EmblemHealth Provider Services: Chautauqua Jefferson St. Lawrence Lewis Franklin Hamilton Clinton Essex Warren Washington Oswego Orleans Niagara Oneida Monroe Wayne Herkimer Fulton Saratoga Genesee Onondaga Montgomery Ontario Cayuga Madison Schenectady Livingston Wyoming Seneca Albany Rensselaer Erie Yates Cortland Otsego Schoharie Tompkins Chenango Schuyler Greene Allegany Columbia Cattaraugus Steuben Tioga Chemung Broome Delaware Ulster Map Color Region Representative Phone Upstate West Janine Fitzpatrick janine.fitzpatrick@dentaquest.com Capital Region Tricia Bell tricia.bell@dentaquest.com Upstate Northeast Sarah Linville sarah.linville@dentaquest.com Hudson Valley Shazmin Garcia shazmin.garcia@dentaquest.com NYC & Bronx Counties Lester Williams lester.williams@dentaquest.com Kings, Richmond, & Healthfirst CAP offices Christine Joseph christine.joseph@dentaquest.com Nassau / Suffolk / Queens / CAIPA Maggie Yeung maggie.yeung@dentaquest.com n/a Healthfirst Owner Hospitals / Aetna NJ Christina Gibson christina.gibson@dentaquest.com 4 Sullivan Orange Rockland New York Kings Richmond Dutchess Putnam Westchester Bronx Suffolk Nassau Queens

5 EmblemHealth Background EmblemHealth is the 2 nd largest not-for-profit health plan in the country; it serves millions of members in the NY and tristate area. In 2005, two independent health insurance companies, GHI and HIP, merged to create EmblemHealth. Today, EmblemHealth maintains products with both the GHI and HIP companies under the umbrella of EmblemHealth. DentaQuest will be assuming administration of all of Emblem s dental plans that reside on the HIP platform. In addition, DentaQuest will be assuming administration of the following Exchange GHI plans. Please note, these GHI plans are not marketed to the general public, so membership for these plans will be low: Off Exchange Individual EPO Bronze (HD6300) Not Marketed Off Exchange Individual EPO Gold (HD1800) Not Marketed Off Exchange Individual EPO Platinum (HD900) Not Marketed Off Exchange Individual EPO Silver (HD2000) Not Marketed Off Exchange Group EPO Bronze(HD6300) (Small Group Not Marketed) All other GHI (PPO) dental plans will continue to be administered by EmblemHealth. 5

6 EmblemHealth Member Services (Medical Inquiries) Medicaid Medicare Exchange Plans Commercial

7 EmblemHealth Products Medicaid/HARP Child Health Plus Medicare Advantage Essential Plans 1+, 2+, 3, 4 On/Off Exchange (QHP) Individual and Small Group HIP Preventive Dental Access Plan* Federal Employee Health Benefit (FEHB)* *for participating Careington International Providers only 7

8 Emblem Service Area Counties MEDICAID/MEDICARE/CHP/HARP/ESSENTIAL PLAN Bronx Kings Nassau New York Queens Richmond Suffolk Westchester Medicaid Members 193,733 CHP Members 11,828 As of April 2017 QHP/EXCHANGE Albany Bronx Broome Columbia Delaware Dutchess Fulton Greene Kings Montgomery Nassau New York Orange Otsego Putnam Queens Rensselaer Richmond Rockland Saratoga Schenectady Schoharie Suffolk Sullivan Ulster Warren Washington Westchester 8

9 EmblemHealth / DentaQuest Highlights No Dental Home No Co-pays for: Medicaid/HARP Child Health Plus Essential Plans 2, 3 & 4 Co-pays may apply for (varies by service*): Medicare Exchange/QHP Essential Plan 1 *Please refer to the ORM for co-pay details 9

10 Medicaid/HARP/CHP Benefit Summary Plan Preventative & Diagnostic Full Comprehensive Co-Pay Medicaid YES YES None HARP YES YES None Child Health Plus (CHP) YES YES* None *very limited orthodontic benefits 10

11 Medicare Individual/Group Benefit Summary Plan VIP Value VIP Premier Value VIP Essential VIP Premier Essential VIP Gold VIP Premier Gold VIP Gold Plus VIP Premier Gold Plus VIP Dual (HMO SNP) VIP Premier Dual (HMO SNP) 1199 SEIU VIP Premier Medicare 1199SEIU VIP Premier Medicare (HMO SNP) Preventative & Diagnostic Full Comprehensive Co-Pay YES NO None YES YES Varies by Service YES YES Varies by Service YES YES Varies by Service YES YES None YES YES Varies by Service YES YES None *Please refer to the ORM for co-pay details 11

12 Essential Plans Benefit Summary Plan Preventative & Diagnostic Full Comprehensive Co-Pay Essential Plan 1 Plus YES YES $15 Essential Plan 2 Plus YES YES None Essential Plan 3 YES YES None Essential Plan 4 YES YES None 12

13 On Exchange Individual Benefit Summary Plan Standard Commercial ADA Categories Type I, II, III Ortho Annual Deductible Individual / Family Co-Pay / Co- Insurance Coverage Type Select Care Platinum YES YES None $15 Pediatric Coverage Only Select Care Gold YES YES $600 / $1200 $25 Pediatric Coverage Only Select Care Silver YES YES $2000 / $4000 $30 Pediatric Coverage Only Select Care Silver CSR1 YES YES $1650 / $3300 $30 Pediatric Coverage Only Select Care Silver CSR2 YES YES $300 / $600 $15 Pediatric Coverage Only Select Care Silver CSR3 YES YES None $10 Pediatric Coverage Only Select Care Bronze YES YES $4000 / $ % co-insurance Pediatric Coverage Only Basic Catastrophic YES YES $7150 / $14300 $0 Pediatric Coverage Only Select Care Silver Value YES* YES None $0 for preventive $35 for routine $55 for major Select Care Silver Value CSR1 Select Care Silver Value CSR2 Select Care Silver Value CSR3 YES* YES None $0 for preventive $35 for routine $55 for major YES* YES None $0 for preventive $35 for routine $55 for major YES* YES None $0 for preventive $35 for routine $55 for major Select Care Bronze Value YES* YES None $0 for preventative $55 for routine $75 for major Family Coverage *Adult Type I & II coverage only Family Coverage *Adult Type I & II coverage only Family Coverage *Adult Type I & II coverage only Family Coverage *Adult Type I & II coverage only Family Coverage *Adult Type I & II coverage only 13

14 Off Exchange Individual Benefit Summary Plan Standard Commercial ADA Categories Type I, II, III Ortho Annual Deductible Individual / Family Co-Pay / Co-Insurance Coverage Type Individual EPO Bronze (HD6300) Individual EPO Gold (HD1800) Individual EPO Platinum (HD900) Individual EPO Silver (HD2000) YES YES $6350 / $12700 $0 Pediatric Coverage Only YES YES $1800 / $ % Co-Insurance Pediatric Coverage Only YES YES $900 / $1800 $0 Pediatric Coverage Only YES YES $2000 / $ % Co-Insurance Pediatric Coverage Only Select Care Platinum D YES YES None $15 Pediatric Coverage Only Select Care Gold D YES YES $600 / $1200 $25 Pediatric Coverage Only Select Care Silver D YES YES $2000 / $4000 $30 Pediatric Coverage Only Select Care Bronze D YES YES $4000 / $ % Co-Insurance Pediatric Coverage Only Select Care Basic YES YES $7150 / $14300 $0 Pediatric Coverage Only Select Care Silver Value D YES* YES None $0 for preventive $35 for routine $55 for major Family Coverage *Adult Type I & II coverage only Select Care Bronze Value D YES* YES None $0 for preventative $55 for routine $75 for major Family Coverage *Adult Type I & II coverage only 14

15 Plan On/Off Exchange Small Group Benefit Summary Standard Commercial ADA Categories Type I, II, III Ortho Annual Deductible Individual / Family Co-Pay / Co- Insurance Coverage Type HMO 15/35 Small Group (OFF) YES NO None $15 Pediatric coverage only Healthy NY Small Group (OFF) YES NO $600 / $1200 $25 Pediatric coverage only HMO 40/60 Small Group (OFF) YES NO $250 / $500 $40 Pediatric coverage only Select Care Silver Value S Small Group (OFF) Select Care Bronze Value S Small Group (OFF) YES* NO None $0 for preventive $35 for routine $55 for major YES* NO None $0 for preventative $55 for routine $75 for major Family Coverage *Adult Type I & II coverage only Family Coverage *Adult Type I & II coverage only Select Care Platinum S (SHOP) YES NO None $15 Pediatric coverage only Select Care Gold S (SHOP) YES NO $600 / $1200 $25 Pediatric coverage only Select Care Silver S (SHOP) YES NO $2000 / $4000 $30 Pediatric coverage only Select Care Bronze S (SHOP) YES NO $4000 / $ % Co-Insurance Pediatric coverage only EPO Select 35/55 Small Group YES NO $3600 / $7200 $15 Pediatric coverage only Off Exchange Group EPO Bronze (HD6350) YES NO $6350 / $12700 $0 Pediatric coverage only 15

16 HIP Preventive Dental Access Plan For participating Careington International dentists ONLY Dental Access Plan that supplements medical and comprehensive dental coverage Members have access to a custom Careington network Members pay providers directly at discounted rates (contracted Careington fee schedule) NO CLAIMS Supplemental add-on to following Emblem plans: HIP and CompreHealth (medical plans) only dental coverage Medicare (VIP HMO Plans and VIP Premier) also have comprehensive dental-waiver needs to be in place before services are provided FEHB also have pediatric preventive dental Benefits: One exam (comprehensive or periodic) every 6 months One prophylaxis every 6 months One topical application of fluoride every 6 months (age 0-16) All other services (x-rays, fillings, crowns, dentures or specialist services) $5 per visit $10 per visit $5 per visit Careington discounted rate Contact Careington directly at option 8 for additional information 16

17 Federal Employee Health Benefit (FEHB) Limited to Pediatric members between the ages of 0-26; preventive services only. DentaQuest is using the Careington rental network for this population. DQ reimburses the provider directly, claims are required. FEHB members also have coverage under the HIP Preventive Dental Access (previous slide) Participating dentists may suggest that members get extra services and procedures consistent with generally approved dental practices. For example, a recent full mouth series of X-rays is needed at the time of exam. Frequency of X-rays depends on the practitioner s judgment of each person s case based upon a number of factors. 17

18 Provider Web Portal DentaQuest is pleased to announce that we have launched a NEW provider portal for EmblemHealth with enhanced functionality, innovative tools, and improved user interfaces! The new portal will host only EmblemHealth members and claims information as an initial rollout. All other DentaQuest-administered plans will continue to be hosted through our standard DentaQuest portal that you use today. Additional NY plans will be migrated over to the new portal during the course of To access important information about EmblemHealth and the new provider portal, we have set up a link to take you directly to this important information: We are interested in hearing provider feedback and suggestions about our new portal Please NYProviderEngagement@dentaquest.com with your feedback 18

19 Emblem Claims Submission Clearinghouses: If you submit your claims through a clearinghouse 837d file it is critical that you have your clearinghouse update the Payer ID for Emblem claims. Payer ID #: EMBDQ If your software does not allow for a Payer ID, please use Payer Name: DQ/Emblem NEW Provider Portal for Emblem Health : If you submit claims through our current provider portal you will need to register on our new provider portal Once registered you can submit Emblem claims and Emblem pre-authorizations here: Paper Claims: If you submit your claims on an ADA Dental Claim form via mail, the address for Emblem claims (only) is: Emblem Dental (DentaQuest) P.O. Box 463 Milwaukee, WI OR Fax Claims to: PLEASE NOTE: The Payer ID and P.O. Box for Emblem are different for all other DentaQuest plans. If you do not use these for Emblem claims, your claims will be routed incorrectly and you will receive a denial letter for Member Not Found. Trading Partner Portal (TPP): If your office submits claim files directly via the DentaQuest TPP, please contact editeam@greatdentalplans.com. You will need to set up an Emblem-specific Trading Partner ID in order to submit claims for Emblem members. 19

20 Explanation of Benefits (EOBs) Clearinghouses: If you receive your EOBs through your clearinghouse (835 file), you will continue to receive your EOBs as you do now. Paper EOBs: If you receive paper EOBs through the mail, you will continue to receive your EOBs as you do now. PDF EOBs via Web Portal: If you retrieve your EOBs through the provider portal, Emblem EOBs will be available once your office is registered on the new portal. by selecting on the left hand margin: ** IMPORTANT NOTE ** Dates of service 01/01/17-03/31/17 must be submitted on or before 06/30/17 for consideration. The ninety (90) file limit will be imposed on all dates of service 04/01/17 and after. 20

21 Verifying Member Eligibility Once registered on the new provider portal you can check eligibility, claims history, and member history for Emblem Health members online. Simply select the below link on the left hand margin: IVR (interactive voice response) is also available 24 hours a day, 7 days a week without having to wait for a live Customer Service Representative! You will need your NPI, Tax ID, Member ID 21

22 Authorizations Authorization requests and documentation must be submitted before treatment begins. Authorization determinations are provided within 3 business days from the date the required documentation is received. Determination letters for non-emergent care are mailed to providers. Determination letters for emergent care are faxed to the provider. Submission Methods: Provider Portal: Once registered select: Mail to: Emblem Dental (DentaQuest) P.O. Box 463 Milwaukee, WI Fax to: Standard Authorization Requests Emergency Authorization Requests

23 Office Reference Manual (ORM) Please use this link to access the Emblem ORM. The Emblem ORM will not be available via the current provider web portal. Benefit Limitations (Criteria and Frequency allowance) Important addresses and phone numbers for DentaQuest Claim submission procedures Member eligibility procedures and sample member ID cards Authorization procedures Appeal procedures Providers rights and responsibilities Participating hospitals by plan Fraud and Abuse Program Quality Management Program 23

24 Continuation of Care-Ortho Approved pre-authorizations from Healthplex prior to 1/1/2017 will be loaded into our system to make providing Continuation of Care as easy as possible for your office. We do recommend, however, that you verify with us that the approved authorization has been transferred to the DentaQuest system by calling You can also find this information on the new provider portal located here: If the Healthplex approval is not on file with DentaQuest, the provider must submit a preauthorization request with a copy of the Healthplex approval and continuation of care form. We must have approval on file or Continuation of Care claims will deny. Please refer to DentaQuest EmblemHealth Office Reference Manual: Page 50 for additional information in regards to Continuation of Care cases 24

25 Transition of Care If you have already started treatment with an EmblemHealth member prior to January 1, 2017 and a decisive appointment* has occurred, please submit your claim to Healthplex directly using the appropriate billing codes for such decisive appointments. Transition of Care will be handled by DentaQuest in cases where a decisive appointment* has not yet occurred. DentaQuest will honor approved prior authorizations from Healthplex for 90 days or through March 31, Approved prior authorizations from Healthplex will be loaded into our system to make providing transitional care as easy as possible for your office. We do recommend, however, that you verify with us that the approved authorization has been transferred to the DentaQuest system by calling *Please refer to the NYS Medicaid Dental Policy & Procedures Manual for more details on decisive appointments (page 25) 25

26 Submitting a Transition of Care Claim to DentaQuest Please use the following process to request reimbursement for Transition of Care services as a participating DentaQuest provider. Payment will be made at the EmblemHealth DentaQuest fee schedule. 1. Verify if your authorization has been transferred to DentaQuest. This can be done by calling Emblem Provider Services at Once you have confirmed the service has properly transferred, you may complete the treatment and submit your claim to DentaQuest. 3. If we do not have your approved Healthplex authorization on file, you must: a. Send claim via your standard process: Portal, fax, clearinghouse, or paper b. Clearly write Transition of Care in the remarks field (box 35) c. Attach the original Healthplex issued approval form *Please refer to the NYS Medicaid Dental Policy & Procedures Manual for more details on decisive appointments. 26

27 Access & Availability Standards All participating providers must comply with NYS IPRO Access and Availability Standards: Routine appointments within 28 days Urgent Appointments within 24 hours Urgent dental appointment examples are a lost filling/crown or Chipped tooth (if it is not causing pain), they do not necessarily require immediate attention Emergent Appointments within 8 hours A dental emergency includes any dental issue that needs immediate treatment that can save a tooth, alleviate severe pain or stop continuous tissue bleeding Offices are surveyed periodically by NYS and DentaQuest Appointment wait time should not regularly exceed one hour 27

28 Credentialing & Recredentialing Applications must be completed in its entirety. If anything is missing this will delay the process Information must be current You will not be eligible to receive payment for treatment of DentaQuest members until you are notified that credentialing has been completed A welcome letter will be mailed with all pertinent information For re-credentialing, updated information must be submitted within the timeframe provided with our request. Failure to do so will result in termination Submit your applications for credentialing & re-credentialing* online via AppCentral at: * Pre-populated re-credentialing applications will only be sent to confirmed secure addresses 28

29 Provider Changes Any changes (i.e., Tax ID, address change, provider additions and terminations) must be sent to DentaQuest in writing via the Provider Change Form to ensure proper payment of your claims as well as accurate directory information for patients Please call Provider Services at if you need a Provider Change Form 29

30 Questions? Please call customer service at or any questions to: We appreciate your dedication to serving patients in your area and look forward to continuing to work with you to make New York smile! 30