Agenda. 1. Our most frequently asked questions 2. Claims we want to help! 3. How to contact us
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1 DentaQuest Indiana
2 Agenda 1. Our most frequently asked questions 2. Claims we want to help! 3. How to contact us 2
3 Frequently Asked Questions 3
4 What Is Benefit Effective Date? For HIP Plus members, coverage for extractions, restorations and crowns are determined by the member s eligibility date. If a member s eligibility date is [June 1, 2016], the member s benefits will roll over [June 1, 2017]. In this example, if a HIP Plus member had 4 extractions on [August 1, 2016], that member would be eligible for 4 additional extractions and/or restorations on [June 1, 2017]. 4
5 How To Find the Benefit Effective Date The member s Benefit Effective Date is listed on our new portal: d 1. Select Patient Management, then Member Eligibility 5
6 2. Once you have searched for a member, click on the member number in blue. 6
7 3. The Benefit Effective Date located below the member detail. 7
8 EPSDT What Is It and How do I Submit an Authorization? Individuals in any HIP plan age 19 or 20 and Hoosier Care Connect or Hoosier Healthwise members ages 0-20 are eligible for Early Periodic Screening, Diagnosis, and Treatment services (EPSDT). Providers should submit such services with an EPSDT designation. 8
9 How to Submit an EPSDT Authorization? a Older Portal: 9
10 New Portal: a Select Claims/Pre-Authorizations, then Submit Claims & Pre Authorizations, under Optional Information, Specialty Program. Indicate PA and select EPSDT. 10
11 11 ADA Claim Form:
12 How To Submit an Appeal Electronically? Older Portal: Tools, Contact DentaQuest, Choose appeals 12
13 How and When To Submit a Corrected Claim When: If an incorrect code or fee was entered on a claim, a corrected claim can be submitted to make adjustments to the incorrect code or fee that was originally submitted. 11 How: In the note section of the claim, add corrected claim with the original claim number. Please only enter procedures that need to be corrected. 13
14 14 Older Portal:
15 15 New Portal:
16 What Is a Peer-to-Peer Call? A provider may request a Peer-to-Peer call with a DentaQuest dentist that reviews claims, any time he or she wants to understand the clinical basis for the decision. The Peer-to-Peer discussion is limited to the clinical aspects of the claim and not administrative issues such as timely filing or member eligibility. The DentaQuest dentist can only discuss clinical information during the call and cannot reverse any denials during the call. How to schedule? Call Customer Service, your Provider Engagement Representative, or schedule through the portal. 16
17 17 Older Portal:
18 Anthem ID Numbers As of April 1, 2017, all Anthem Healthy Indiana Plan (HIP), Hoosier Care Connect (HCC) and Hoosier Healthwise (HHW) have a nine digit ID number. When looking up a member on our portal or calling our Customer Service department, you will need to use the nine digit Anthem ID number to locate the member. When looking on the member on CoreMMIS, you will need to use the twelve digit Medicaid ID number to locate the member. 18
19 How To Locate an Anthem ID Number on Our Portals? Older Portal: Select Patient, then select Member Eligibility. Search by the member s first and last name along with date of birth only. Older Portal: 19
20 New Portal: Choose Patient Management, then select Member Eligibility and enter member first and last name along with date of birth only. 20
21 How Are Claims Reviewed? There are three levels of claim review: 1. Automatic review of claims that ensure basic information is correct such as verifying the eligibility of the member. 2. If a claim requires clinical review, it is reviewed by a Clinical Review Specialist (CRS). All Clinical Review Specialists are certified dental assistants or registered dental hygienists and receive rigorous training in claims adjudication. 21
22 3. If a Clinical Review Specialist determines that a claim should be denied based on a clinical interpretation, the claim is sent to a licensed dentist for further review. The decision to deny a claim for clinical purposes can only be made by a dentist. All DentaQuest personnel involved in reviewing claims, CRSs and dentists, take quarterly examinations called Inter-Rater Reliability (IRR) tests to ensure that claims are being adjudicated in a consistent manner. 22
23 How to Look Up Members on CoreMMIS 1. Select Medicaid program 23
24 2. Select Expand All Review Managed Care Assignment Details, MCO/CMO : Anthem - claim is sent to DentaQuest (use Anthem ID#) MDWise - claim is sent to DentaQuest If there is not a Managed Care assignment, the member s claim should be sent to IHCP/ DCX Technology. 24
25 25
26 Code Specific Questions 26
27 Sedation Authorization for [D9243, intravenous moderate (conscious) sedation/ analgesia each 15 minute increment for members that are 21 and older]. For members that are under 21, no authorization is required. Authorization for [D9223, deep sedation/general anesthesia - each 15 minute increment]. Authorization documentation should include treatment to be rendered and description of medical necessity. No more than 6 units per day per member. Providers should submit anesthesia record for each member, per date of service. 27
28 Stainless Steel Crowns D2930 is [once per lifetime, per patient per tooth]. 28
29 X-rays As is common in the insurance industry, DentaQuest bundles radiographs taken on or near the same date of service by the same provider or location. Radiographs submitted with claims must be of diagnostic value. 29 o Digital images are preferred and can be submitted through the DentaQuest portals or the NEA. o If digital images cannot be submitted, we encourage submission of duplicate films, however they cannot be returned. o Original films will be returned if a self-addressed stamped envelope is supplied with the claim. o Photocopies of x-ray films are discouraged as they are rarely of diagnostic quality.
30 Alveoloplasty D7310 and D7311 Providers will be reimbursed when an alveoloplasty is preformed in conjunction with a routine extraction. Providers will not be reimbursed when an alveoloplasty performed in conjunction with a surgical extraction. Alveoloplasty does [not] require authorization. Claim should be submitted with pre operative x-rays and/or digital images. 30
31 Incision & Drain D7510 is reimbursable when an extraction is not performed on the same day. 31
32 We want to hear from you! 32
33 Indiana Provider Advisory Committee (IPAC) DentaQuest is forming a Provider Advisory Committee to better serve the provider community. The committee will meet telephonically, every quarter, and focus on improving the administration of the programs by receiving input and identifying benefits for review or clarification, discussing opportunities to outreach and educate members on overall oral health. If you know of a provider that would be interested in participating, please reach out to your Provider Engagement Representative. 33
34 How to Contact your Provider Engagement Representative? 34
35 Stephanie Nester Cindy Cobb Melanie Brune Courtney Stanton 35
36 [Melanie Brune, Counties Served: Boone, Carroll, Cass, Clinton, Fountain, Howard, Marion, Montgomery, Tippecanoe, Tipton, Vermillion, and Warren] [Cindy Cobb, Counties Served: Adams, Blackford, Clark, Dearborn, Decatur, Delaware, Fayette, Floyd, Franklin, Grant, Hamilton, Hancock, Henry, Huntington, Jay, Jefferson, Jennings, Madison, Miami, Ohio, Randolph, Ripley, Rush, Scott, Shelby, Switzerland, Union, Wabash, Wayne, and Wells] 36
37 [Stephanie Nester, Counties Served: Allen, Benton, DeKalb, Elkhart, Fulton, Jasper, Kosciusko, LaGrange, Lake, LaPorte, Marshall, Newton, Noble, Porter, Pulaski, Starke, Steuben, St Joseph, White, and Whitley] [Courtney Stanton, Counties Served: Bartholomew, Brown, Clay, Crawford, Daviess, Dubois, Gibson, Greene, Harrison, Hendricks, Jackson, Johnson, Knox, Lawrence, Martin, Monroe, Morgan, Orange, Owen, Parke, Perry, Pike, Posey, Putnam, Spencer, Sullivan, Vanderburgh, Virgo, Warrick, and Washington] 37
38 38 Questions?
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