WYOMING MEDICAID PROVIDER MANUAL. Dental Services

Transcription

1 WYOMING MEDICAID PROVIDER MANUAL Dental Services

2 Table of Contents AUTHORITY... vi Chapter One General Information How the Billing Manual is Organized Updating the Billing Manual State Agency Responsibilities Fiscal Agent Responsibilities Quick Address and Telephone Reference Chapter Two Verifying Recipient Eligibility Recipients with Cards Regular Medicaid Recipients - Green Card Qualified Medicare Beneficiaries (QMBs) - Buff Card Presumptive Eligibility - White Card Other Types of Eligibility Identification How to Read the Recipient Identification Card Recipients Without Cards DFS 611 Foster Care Authorization Form Minimum Medical Program (MMP) Recipients Notice of Award Aliens Eligible for Emergency Services Emergency Medical Services Approval Emergency Medical Services Notice History Using Eligibility Verification Systems (EVS) Automated Voice Response (AVR) Provider Terminal Network Chapter Three Third Party Liability What is Third Party Liability (TPL)? How to Identify TPL How to Bill Third Party Payers What are the exceptions to Third Party Billing? When the policy holder of the other insurance is an absent parent When legal liability has not been established Questions about TPL Why should I care about TPL? Who pays the bill when a recipient has other insurance? i

3 Can I refuse to accept Medicaid patients with other insurance if my office doesn't bill other insurance? When can I bill a recipient? Wyoming Health Insurance Premium Payment Program What is WHIPP? Benefits to recipients Benefits for all Wyoming residents What will Medicaid cover under the WHIPP program? What recipients must do to enroll in WHIPP? Chapter Four Billing Instructions Choosing the Correct Claim Form Coding Requirements (CDT-3) How to Complete the ADA Dental Claim Form Basic Rules Before You Begin Instructions for Completing the ADA Dental Claim Form Prior Authorization How to Bill for Newborns Medical Necessity Instructions for Completing the Documentation of Medical Necessity Form Where to Send Your Claim How to Resubmit a Denied Claim The Remittance Advice When Your Patient Has Other Insurance Sample Remittance Advice How to Read Your Remittance Advice Adjustments and Refunds Refunding Money to Wyoming Medicaid Incorrectly Billed or Keyed Claims Third Party Recovery After Medicaid's Payment How to File a Void or Adjustment Request How to Complete the Adjustment Request Form Where to Send the Adjustment Request Chapter Five Electronic Media Claims What is Electronic Media Claims Submission (EMC)? Types of Electronic Media Claims Transmissions Getting Started in EMC The Future in Medicaid Claims Processing Training Equipment ii

4 Cost Benefits Chapter Six Getting Help When You Need It Provider Services Available How to Call for Help How to Write for Help How to Get On-Site Help Ordering Claim Forms Order Form Training Workshops Chapter Seven Recipient Eligibility Policy Eligibility Determination Responsible Agency Eligible Individuals Qualified Medicare Beneficiaries Special Low Income Medicare Beneficiary Presumptive Eligibility Newborns Aliens Eligible for Emergency Services Definition of Emergency Services Verification of Recipient Data Verification of Recipient Eligibility Recipient Identification Verification of Recipient Age Recipients Without Cards Responsibility for Provider Payment Assistance to Potential Eligibles Timely Filing Requirements in Conjunction with Retroactive Eligibility Recipient Lock-In Freedom of Choice Chapter Eight Provider Responsibilities Enrollment Changes in Enrollment Recertification Termination Accepting Medicaid Patients Compliance Requirements iii

5 Provider-Patient Relationship Medical Necessity Forms Policy Medicaid Payment is Payment in Full Out-of-State Service Limitations WMSA Border Cities Other Service Limitations and Exclusions Usual and Customary Charges No Show Appointments Authorized Signatures Timely Filing Timely Filing Criteria Exceptions to the Twelve Month Limit Appeal of Timely Filing How to Appeal Important Information Regarding Retroactive Eligibility Decisions Failure of Eligible Recipient to Notify Provider of Medicaid Eligibility Billing Tips to Avoid Timely Filing Denials Filing Deadlines for Adjustments Record Keeping, Retention, and Access Requirement Retention of Records Access to Records Audits and On-Site Visits Chapter Nine Covered Services Introduction Dental Services for Patients Under the Age of Examinations Radiographs and Diagnostic Imaging Preventive Dental Care Restorative Treatment Crowns Labial Veneers Endodontia Apicoectomy Periodontal Treatment Implant Services Oral and Maxillofacial Surgery Interceptive Orthodontic Treatment Anesthesia Behavior Management Covered Dental Services for Patients Age 21 Years and Older Procedures Common to Dentistry and Medicine - All Ages iv

6 Maxillofacial Prosthetics Oral and Maxillofacial Surgery Temporomandibular Joint (TMJ) Treatment Policy Medical Necessity Reimbursement Prior Authorization and Utilization Review Non-Covered Services Orthodontics Chapter Ten Utilization Review Utilization Review Complaint Referral Release of Clinical Records Recipients Lock-In Fraud and Abuse Definition of Fraud Definition of Abuse Provider Responsibility Referral of Suspected Fraud and Abuse Sanctions Adverse Action Report of Suspected Abuse of the Medicaid Health Care System Appendix A Social Security Administration District Offices... A-2 Appendix B County DFS Offices... B-1 -B-3 v

7 AUTHORITY The Wyoming Department of Health is the single State agency appointed pursuant to the Social Security Act to administer the Medicaid program in Wyoming. The Division of Health Care Financing directly administers the Wyoming Medicaid program in accordance with the Social Security Act, the Wyoming Medical Assistance and Services Act, (W.S et seq.), and the Wyoming Administrative Procedures Act (W.S et seq.) This manual is intended to be a guide for the provider when filing dental claims with the Wyoming Medicaid program. The manual is to be read and interpreted in conjunction with Federal regulations, State statutes, administrative procedures and Federally approved State Plan amendments. This manual does not take precedence over Federal regulation, State statutes or administrative procedures. vi