Presented by: Jan Paulsen, Program Officer PROVIDER RATE CHANGE During the 64 Legislative Session, an estimated 2% provider th rate increase was approved. Check the website for a copy of the newest fee schedule, and the newest provider manual reflecting the rate increase and any program changes. This is likely to be implemented effective July1, 2015. www.medicaidprovider.mt.gov provider type
click on resources by MT MEDICAID SUPPORTS A NEW PRACTICE STANDARD: AbCd Access to Baby and Child Dentistry- AbCd First Birthday, First Dental appointment Dentists must receive continuing education in early pediatric dental techniques to qualify as an AbCd specialist. This specialty endorsement will allow AbCd Dentists to be reimbursed for the following procedures: D0145, Oral evaluation (age 0-2),
D0425, Caries Susceptibility Test (age 0-2) D1310, Nutritional Counseling (age 0-5), D1330, Oral Hygiene Instruction (age 0-5). Currently there are 185 Medicaid AbCd trained dentists
FREQUENTLY ASKED QUESTIONS 1. Can I limit the numbers of Medicaid patients I see in my office? Yes, simply make a business decision as to how many Medicaid members your office can handle. Many offices do this. 2. Can I accept or reject them on a case by case basis? Yes, as long as you do not discriminate. When you sign-up as a Medicaid provider you agree not to discriminate on the grounds of race, creed, religion, color, sex, national
origin, marital status, age or disability. 3. Will I be listed anywhere as a Medicaid provider? Yes, the department does maintain a list of participating providers on the Web Portal, Montana Access to Health. An updated list of dental providers who are currently accepting Medicaid patients is also on the Departments web site, www.medicaidprovider.mt.govand updated quarterly. TOP 3 FRUSTRATIONS 1. NO SHOW/BROKEN APPOINTMENTS Each office is encouraged to have a general office procedure
for reminders. All patients need to be treated the same in terms of reminders and no shows. Cannot bill patient. There are a variety of best practices, find what works for your office. Consistency is important. No show, no procedure performed, nothing to claim. Cannot bill patient. 2. MINIMIZE ADMINISTRATIVE HASSLES
Use the ADA form dated 2012. Attach special forms, such as Essential for Employment, Emergency Dental form or EOB for other insurance. Staple any form on top of the claim. Document disability or the reason for exceeding limits in box 35.
Include PA# in box #2, do not attach the approval notice. Consider filing electronically. Follow-up e!SOR sooner than later. 3. REIMBURSEMENT TOO LOW? File claims with your Usual and Customary fee. Get paid for what you do, verify eligibility, check fee schedule, be aware of allowable procedures, limits, etc. If prior authorization is required make sure you go through the process and put the # in box 2. OTHER BARRIERS IDENTIFIED
Limited availability of dental providers; Lack of clear information for beneficiaries explaining their dental benefits; Transportation (1-800-292-7114); Cultural and language competency; Need for consumer education about the benefits of dental care. VERIFYING CLIENT ELIGIBILITY Fax Back: 800-714-0075 Automated Voice Response (AVR): 800-714-0060
Web Portal: https://mtaccesstohealth.acs-shc. com/mt/secure/home.do Xerox Provider Relations: 800624-3958 Site Contents WEB SITES: Montana Access to Health (aka Web Portal, requires login) Department Website (open to the public) www.medicaidprovider.mt.gov
https://mtaccesstohealth.acs-sh c.com/mt/secure/home.do Check eligibility. Resources by Provider Type (manuals, fee schedules, Claim Status. notices, etc.). Provider Information Page. Claim Jumper newsletter.
Link to log onto to MT Access to Health Web Portal. Link to update provider file. Client information, how to locate a healthcare provider. Payment summary. e! SOR. MONTANA DENTAL RATE SETTING PROCESS The Department reimburses dental and denturist services on a fee for service basis. Reimbursement rates are established
by multiplying a nationally recognized unit value for each procedure by the Departments conversion factor. Relative Values for Dentists (RVD) is an accurate and comprehensive relative value system. The relative values for each procedure are determined by dental practitioner input. 6 Criteria are used to rate each procedure. THE SIX CRITERIA USED TO RATE A PROCEDURES VALUE 1. Time 2. Skill
3. Risk to the patient 4. Risk to the dentist (medico-legal) 5. Severity of the problems (i.e., emergent, acute, chronic, prophylactic) 6. Unique supplies not separately billable DEPT. CALCULATION OF RATE 1. 2. 3. 4.
5. 6. 7. Determine utilization of each procedure from previous year. Multiply each procedure codes utilization by its unit value based on the Relative Values for Dentists. Obtain the upcoming years budget amount. Total budgeted $ amount is divided by previous years utilization of all procedures. The result determines the MT Medicaid Dental conversion factor (CF) = $32.53 for SFY14. The rate for each procedure is determined by multiplying the unit value by the conversion factor. Examples:
(a) (b) D1110 has a unit value of 1.50 multiplied by the CF = $48.80 D2140 has an assigned unit value of 2.0 times CF = $65.06. WHO IS ELIGIBLE FOR DENTAL SERVICES Patients on FULL Medicaid Aged, Blind, Disabled, 20 yrs. and under and Pregnant woman. Patients on BASIC Medicaid
IF: They are approved under: Essential for Employment or Emergency Services. WHAT NEEDS SPECIAL PROCESSING Check limits Prior Authorizing (PA) Diagnostics All Orthodontia
Radiographs Veneers Prophys and Fluoride Crowns Periodontics Dentures, full/partial Crowns: NO PA effec 8-1-12 Orthodontia Services Prior Authorization Process: HLD-Index, pano, ceph and photos.
Banding fee (D8050, D8060, D8070, D8080, and D8090, Periodic visits (D8670), de-band and final retention (D8680). Eligibility must be on-going, private pay agreement in place. TPL-Blanket Denial. FORMS: www.medicaidprovider.mt.gov ADA Dental Claim Form, Prior Authorization box checked Handicapping Labio-Lingual Deviations Form (HLD Index)
Revised 9/2013, added posterior impactions and anterior crossbite www.medicaidprovider.mt.gov N New CROWNS FOR ADULTS D2751 2 per calendar year per person Second Molars:
#2-15-18-31= D2791 Effective 8-1-12, NO PA needed EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT - EPSDT When a Medicaid-eligible child (20 and under) requires medically necessary services, those services may be covered under Medicaid even if they are not typically covered services or if periodic limits need to be waived. Documentation of
Medical necessity is VITAL. MEDICAL NECESSITY DEFINITION ARM 37.79.102 (23) "Medically necessary" or "medically necessary covered services" means services and supplies which are necessary and appropriate for the diagnosis, prevention, or treatment of physical or mental conditions as described in this subchapter and that are not provided only as a convenience.
Medical Necessity: Medicaid does not cover cosmetic dental services. NEW 8-1-2011 Veneers require prior authorization (PA) Provide a diagnosis that is requiring this treatment plan. D2960 D2961 D2962 BE IN THE KNOW! PA means prior authorization NOT
periapical. What are the first two questions JAN will ask you when you call? 1. Member ID (Use Medicaid ID not SS#) 2. Date of service. Resources by Provider Type: www.medicaidprovider.mt.gov Multiple units. Pay to dentist and Rendering dentist. REVIEW OF WHAT WAS NEW IN 2014
Caries risk assessment finding: Use like Diagnosis codes at the line level: D0601 Low risk, D0602 Moderate risk, D0603 High risk. No reimbursement. ADA deleted D0363 three-dimensional cone beam, new code with Medicaid D0367, similar scope of service. D2740 crown anterior AND posterior age 20 and younger. By Report codes have gone away D2999, D4999, D5899, D6999, D7999. D9999 will be payable with PA only (for anesthesia travel). NEW IN 2015 Dental Advisory Committee (DAC) General Dentist
Denturist Pediatric Dentist Orthodontist Oral Surgeon Dental Hygienist MT Dental Association DPHHS PRIVATE PAY AGREEMENT The agreement to pay privately must be in writing and based upon definite and specific information given by the provider to the member prior to the services being delivered/performed indicating that the service will not be paid by Medicaid. This gives them the option to deny the service. The private pay agreement must be
in writing per occasion. This does not include routine and general contracts signed by the member at the time of acceptance into the office. Providers can not pick and choose which codes to have members privately pay. If it is a covered service by Medicaid they must accept the fee in full. If it is not on the fee schedule it can be pre-agreed for private pay. ARM 37.85.406 (11)(1) REVISED ADA CLAIM FORM 2012 The ADA Dental Claim Form has been revised to incorporate key changes to the HIPAA standard electronic dental claim transaction. Some of the changes
include the reporting of diagnosis codes and diagnosis code pointers, place of service codes, and other medical and dental coverage. It also includes a column for units of service. Begin using the form now. Required 1/2015. RECORD KEEPING The dental record must be: Authentic Legible Objective Clear on the disease condition that made the treatment necessary
#1 Rule of Documentation If you didnt write it, It didnt happen! NEW CLAIM SYSTEM COMING Montana Health Care Programs will be supported by Health Enterprise Claim Payment system. This new claim payment system will be able to accept claims electronically; on-line or transmitted through your software. Provider enrollment and payment will also be updated providing for a Provider Inbox to receive your important documents. Letter generation to members, eligibility check, claim status, etc. will all be made more
efficient. CHIPRA LEGISLATION List of dental providers who are currently accepting Medicaid for under age 21 will be posted. Updated quarterly, expect an e-mail! www.insurekidsnow.gov CMS/HRSA/IKN completes annual survey to verify data. MONTANA STATISTICS SFY14 1. 405 Enrolled Dentists, Denturist and Hygienists.
Dental related expenditures SFY14: $26 million+ 3. Served 42,410 recipients 4. Personal Transportation SFY13: 2.8 million+ Call center 1-800-292-7114 2. HOW WE COMMUNICATE WITH YOUR OFFICE Notices from MMIS www.medicaidprovider.mt.gov Provider Notices Fee Schedules Provider Manuals Remittance Advice
Claim Jumper Web Portal https://mtaccesstohealth.acs-shc.com/mt/secure/home .do AGAIN-PROCEED WITH CAUTION REFER TO THE PROVIDER MANUAL There may be limits, per procedure, per tooth, per quadrant, anterior/posterior, or prior authorization requirements. See the fee schedule and provider manual on-line for current reimbursement rates. Additional resources can be found at: www.medicaidprovider.mt.gov
click on resources by provider type. ACS Provider Relations: 1-800-624-3958 THANK YOU FOR YOUR TIME! I am a resource as well, feel free to contact me with any further questions or unique issues to discuss,
Jan Paulsen Medicaid Dental Program Officer PO Box 202951 Helena MT 59620-2951 [email protected] Phone: 406-444-3182 FAX: 406-444-1861
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