Dental Refresher Workshop Presented by The Department of Social - - PowerPoint PPT Presentation

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Dental Refresher Workshop

Presented by The Department of Social Services & HP Enterprise Services

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Training Topics

• Provider Bulletins
• Electronic Messaging
• Client Eligibility
• Provider Enrollment and Re-enrollment
• Demographic Maintenance
• Dental Fee Schedule
• Prior Authorization
• Program Limitations
• Web Claim Submission
• Frequent Claim Denials
• Messages Archived
• ICD-10 Updates
• Available Resources
• Questions

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Provider Bulletins

Provider Bulletins

• Access the Publications page by selecting Publications from

either the Information box on the left hand side of the home page (www.ctdssmap.com) or from the Information drop- down menu.

• Bulletin Search allows you to search for specific bulletins (by

year, number, or title) as well as for all bulletins relevant to your provider type.

• When searching by provider title, you can search by any

word as long as that word is in the title of the bulletin.

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Provider Bulletins

Provider Bulletins – Searching by Year and Type

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Provider Bulletins

Recent Dental Provider Bulletins:

• Provider Bulletin 2015-27 “ Changes in Dental Coverage

for Bitewings”

»

Effective May 1, 2015 there is a limitation of one time bitewing radiographs per calendar year for members under the age of 21.

• Provider Bulletin 2015-15 “ Dental Regulations Regarding

Placement of Amalgam Restorations”

»

Medicaid does not cover resin-based composite restorations to the molar teeth (tooth numbers 1, 2, 3, 14, 15, 16, 17, 18, 19, 30, 31, and 32)

• Provider Bulletin 2014-71 “ Tobacco Cessation; New

Screening Code and Program for Dental Hygienists”

»

D1320 tobacco counseling payable to dental providers effective October 1, 2014.

»

D0120 not payable to dental hygienists as of 10/1/2014. New codes to be used are D0601-3.

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Provider Bulletins

Recent Dental Provider Bulletins:

• Provider Bulletin 2014-62 “ Update to the Medicaid Dental

Services Fee Schedule and Policy”

»

New codes were added to the Dental Fee schedule and some codes were removed; reimbursement was adjusted for specific codes.

»

Age restrictions for specific codes.

»

Code restrictions for specific specialties, which meant changes to prior authorization/post procedure review requirements for designated specialties.

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Effective September 1, 2014, both children and adults are eligible for four problem focused evaluations (D0140) per calendar year.

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Effective October 1, 2014, all clients who reside in long term care facilities are eligible for an additional cleaning, fluoride and examination (twice yearly rather than once yearly) without prior authorization.

»

Tooth Surface Designation for specific teeth - Dental providers to be reimbursed for the total number of surfaces restored on a single tooth per one year period for each provider.

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Provider Bulletins

Provider Bulletins – Searching by Title

• Searching by the word “Electronic Messaging”,” only brings up

bulletins with the word “Electronic Messaging” in the title of the bulletin.

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Electronic Messaging

• Provider Bulletin 2015-23 “Implementation of Electronic

Messaging - Replacement to the Mailing of Bulletins/Policy Transmittals”

• The Department of Social Services (DSS) and HP are pleased

to announce the implementation of electronic messages replacing the mailing of bulletin/policy transmittals.

• Dental providers and their office staff can subscribe to receive

pertinent Connecticut Medical Assistance Program (CMAP) program information via e-mail messages.

• DSS will no longer distribute any paper communications to

providers as of June 30, 2015.

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Electronic Messaging

• DSS and HP will use electronic messaging to distribute:
• Provider bulletins and policy transmittals.
• Workshop invitations.
• Program updates and reminders.
• There are many benefits to the electronic delivery of

communication.

• Faster distribution of information to the provider

community.

• Any office personnel can subscribe to receive program

information via e-mail.

• Provides a simplified subscription process that can be

completed very quickly allowing information to get into the right hands.

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Electronic Messaging

• To subscribe for electronic messaging, providers and office

staff must perform the following steps:

• Access the www.ctdssmap.com Web site.
• Select Provider > E-mail Subscription from the drop-down

menu.

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Electronic Messaging

• Once on the E-mail Subscription page, enter the e-mail

address you wish to subscribe under New Subscriber.

• Re-enter the e-mail address for verification and click

Register.

• A confirmation message will be displayed at the top of the

page.

• If you receive an error message, correct the error(s) and

click Register again.

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Electronic Messaging

• From the right hand side of the page, use the checkboxes to

select the available subscriptions you would like to receive.

• Once complete, select Save.

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Electronic Messaging

• Providers that supplied e-mail addresses at the time of

enrollment or re-enrollment in CMAP, or during the setup of their Secure Web portal account, will automatically be subscribed for e-mail notifications.

• Please note that the email addresses on file for clerk

accounts will not be included in the auto-subscribe process and will need to subscribe separately.

• Once you have subscribed, you may modify your

subscriptions at any time by performing the following steps.

• Access the www.ctdssmap.com Web site.
• Select Provider > E-mail Subscription from the drop-down

menu.

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Electronic Messaging

• Once on the E-mail Subscription page, enter the e-mail

address you wish to modify in the Existing Subscribers section of the panel and click Update.

• From the right hand side of the page, use the checkboxes

to modify your subscriptions and click Save.

• Once you have successfully modified your subscriptions, you

will receive a confirmation notice that includes the provider type(s) and/or topic(s) you selected from the checkboxes.

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Electronic Messaging

• To Unsubscribe your subscription, you will need to take the

following steps:

• Access the www.ctdssmap.com Web site.
• Select Provider > E-mail Subscription from the drop-down

menu.

• Once on the E-mail Subscription page, enter the e-mail

address you wish to unsubscribe in the Unsubscribe section

• f the panel. Once complete, click Unsubscribe.
• A confirmation message will be displayed at the top of the

page.

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Client Eligibility - Verification

DSS recommends that providers verify a client’s eligibility on the date of service prior to providing services.

To verify a client’s eligibility through the secure Web site www.ctdssmap.com – click on the Eligibility tab on the main menu.

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Client Eligibility - Verification

Search by Service Type Codes

• Providers have the option to search up to five (5) different

service type codes. The service type codes allow providers to verify the client’s eligibility benefit coverage for specific services.

• The first service type code field defaults to 30 – Health

Benefit Plan Coverage. If the provider searches by that default selection, it will return with all the service type codes that are covered for the client’s benefit plan.

• The specific service type code for Dental providers is “35”

for “Dental Care.”

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Client Eligibility - Verification

• Enter enough data to satisfy at least one of the valid search

combinations; click search.

• When entering a full name as part of your search, a

middle initial is required if present in his/her CMAP profile.

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Client Eligibility - Verification

Search by Service Type Codes 35 – Dental Care

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Client Eligibility - Verification

HUSKY B client eligibility search response

• HUSKY B copay amounts will not show on the eligibility screen,

provider should refer to the dental fee schedule.

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Client Eligibility - Third Party Liability (TPL) Update

To correct or update Third Party Liability (TPL) information: You must obtain a TPL form from the following options:

• Print out form located on Web site at www.ctdssmap.com under

Information → Publications → Forms →Third Party Liability Forms→ TPL Information Form.

• Call Health Management System, Inc. (HMS) 1-866-277-4271.

HMS staff will mail or fax the form to the provider.

• E-mail request to ctinsurance@hms.com and form will be e-

mailed back to provider.

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Client Eligibility - TPL Update

Submit completed forms mail to: Health Management Systems, Inc. Attn: CT Insurance Verification Unit 5615 High Point Dr. Suite 100 Irving, Texas 75038

• Fax to HMS with HIPAA compliant cover letter to 866-389-5451.
• Scan completed forms and submit through e-mail to

ctinsurance@hms.com.

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Client Eligibility - Access Health CT (AHCT) Newly Eligible Clients

• The “Eligibility Decision for Health Care Coverage” notice serves

as proof of eligibility and must be presented to the provider in

• rder to act as a guarantee of payment. A copy of a sample

notice can be found in Provider Bulletin 2014-01 “Newly Eligible Clients under the Affordable Care Act”.

• In the event that an individual presenting an AHCT “Eligibility

Decision for Health Care Coverage” notice does not have an eligible client ID in the Automated Eligibility Verification System (AEVS) or the Secure Web portal, providers may contact HP to have a temporary client ID issued. Please note that only HUSKY A and HUSKY D eligible individuals will be granted temporary identification numbers.

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Client Eligibility - AHCT Newly Eligible Clients

• Providers can contact the HP Provider Assistance Center at

1-800-842-8440 and select #2 “Claim & Enrollment Assistance” from the main menu and then option #4 for Access Health CT Eligibility.

• Temporary IDs will begin with an “8”.
• This temporary client ID will allow dental providers to submit

claims to CMAP. –Except for services that require prior authorization (PA). Services that require PA will deny if submitted with a temporary ID. –Dental providers will have to wait until a valid ID is granted, obtain a PA, and once PA is approved they can submit their claims for processing.

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Client Eligibility - AHCT Newly Eligible Clients

• Once the client is granted an active ID, if you perform an

eligibility search on the Web using the temporary ID, it will return with the current ID.

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Client Eligibility - AHCT Newly Eligible Clients

• If you perform an eligibility search on the Web using Full Name

and either date of birth or social security numbers and get a response “Client ID is deactivated, active ID should be used.” This means the client has received an active number.

• To get the active number, you might have to change your

search, please search using the temporary ID or the client might be loaded with a middle initial. If you do not have a middle initial you will need to contact HP Provider Assistance Center (PAC) for the middle initial.

• Once you have the complete full name, you will be required to

perform the eligibility search on the Web again. PAC cannot provide you with the client ID number.

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Client Eligibility - AHCT Newly Eligible Clients

• Claim processed using temporary IDs will be voided once the

active ID is granted. –Claims with the temporary ID will be voided under ICNs beginning with “52” and EOB code 8231 “ Claim Recoupment Due to Voided Payment.”

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Client Eligibility - AHCT Newly Eligible Clients

• Once the claim has been voided the claim is then processed

under the active ID, with an EOB code 8250 “Claim Reprocessed with EMS recipient ID. Original Claims with AHCT Temp ID Recouped.”

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Provider Enrollment and Re-enrollment

• The Department of Social Services (DSS) allows a majority
• f

providers to enroll/re-enroll

• n
• ur

Web site www.ctdssmap.com.

• A majority of the required information on a re-enrollment

application is automatically populated based on the provider’s previous contract information.

• Online

re-enrollment cannot be initialized until an Application Tracking Number (ATN) is received from the HP Provider Enrollment Unit.

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Provider Enrollment and Re-enrollment

• Select Provider Enrollment from either the Provider box on

the left hand side of the home page or from the Provider drop-down menu; select Provider Re-Enrollment from the Provider drop-down menu.

• Re-enrollment Period: Dental providers are required to re-

enroll every 2 years.

• Re-enrollment via the Enrollment/Re-enrollment Wizard on the

CMAP Web site, www.ctdssmap.com, is required.

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Re-enrollment Notification and Process:

• Dental providers will receive a reminder letter when they

are due for re-enrollment six (6)months prior to the end of their current contract (Reference Provider Bulletin 2014- 52).

• It is imperative that providers successfully complete

the re-enrollment application as quickly as possible upon receipt of their notice.

Provider Enrollment and Re-enrollment

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Follow on Documents:

• Once the enrollment/re-enrollment application is submitted,

providers are notified of any follow on documents that need to be mailed to HP’s Enrollment Unit.

• The document requirements vary by provider specialty.
• The enrollment/re-enrollment application is not considered

complete until all the required documents have been received.

• Providers with re-enrollment applications that are not fully

completed by the provider’s re-enrollment due date will receive a notice advising they have been dis-enrolled from CMAP.

Provider Enrollment and Re-enrollment

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Follow on Documents: Providers can access the follow on document requirements from www.ctdssmap.com by clicking Provider > Provider Matrix > Follow on Document Requirement by Provider Type and Specialty.

Provider Enrollment and Re-enrollment

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• Re-enrollment Due Dates:
• Providers with Secure Web portal access can view their re-enrollment due

date once logged in!

• Individual providers can view their re-enrollment due date on the

Home page.

• Organizations can view their re-enrollment due date, as well as the re-

enrollment due date of their members by accessing the “Maintain Organization Members” panel.

• This enhancement will allow individual providers and
• rganizations to better track their re-enrollment due dates

prior to receiving their notice to re-enroll.

Provider Enrollment and Re-enrollment

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Provider Enrollment and Re-enrollment

Performing Providers:

• Billing

groups need to associate their performing providers to the group since performing providers are now enrolled/re-enrolled independent of the groups they belong to.

• The performer would re-enroll according to their re-

enrollment due date which may be different from the group.

• The re-enrollment letter will only be sent to one address if

the performing provider belongs to more than one group.

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Provider Enrollment and Re-enrollment

• To check the status of an enrollment/re-enrollment

application, select “Provider Enrollment Tracking” from either the “Provider” submenu or the “Provider” drop-down menu.

–Enter your “ATN” and “Business OR Last Name” and click “search.”

• In this example, HP is reviewing the application that was

submitted by John J. Smith on April 30, 2015.

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Demographic Maintenance

DSS requires providers to update their demographic information

via their secure Web account. Demographic information includes provider addresses, Electronic Funds Transfer (EFT) and member of organization maintenance. The main account administrator must log on to their account and click on the “Demographic Maintenance” tab. See Chapter 10 of the Provider Manual for more information.

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Demographic Maintenance – Address Updates

Specify different mailing, payment, service location, and enrollment addresses.

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Dough Financial 2500 Main Street Willimantic CT 06060 1234

The EFT Account panel allows you to add and maintain bank accounts into which reimbursements from CMAP will be electronically deposited.

• Click “add”; enter the appropriate information; and click

“save.” **This action will place the provider in a pre-notification status**

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Demographic Maintenance – Maintain Organization Members

• The Maintain Organization Members panel allows you to:
• Search current or historical members using the search button.
• Add new members by entering their Organization Member ID

(NPI) as well as Effective Date.

• Separate members by selecting their line and entering an End

Date.

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Demographic Maintenance – Maintain Organization Members

When enrolling or attaching a performing provider to a group, the provider must be the same specialty as the group that it is being tied to.

• Example:

A Dental group with an Endodontist Specialty(270) cannot have a Pediatric Dentist Specialty (274) attached to it.

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Re-enrollment due dates are now visible on the maintain

• rganization panel.

Demographic Maintenance – Maintain Organization Members

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Dental Fee Schedule

• Select Provider Fee Schedule Download from Provider menu.
• Click “I accept” to the Connecticut Provider Fee Schedule End

User License Agreement page.

• Provider Fee Schedules are listed by provider type. Choose

Dental by clicking on the CSV link.

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Dental Fee Schedule Dental Fee Schedule dated 9/1/2014, Last Updated on

2/18/2015.

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Dental Fee Schedule

• PR means Post Authorization Review is required to be
• btained from Connecticut Dental Health Partnership(CTDHP)

AFTER the service has been performed.

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Dental Fee Schedule

• PA means Prior Authorization is required to be obtained from

CTDHP BEFORE the service is performed.

• <21 means that Prior Authorization is required for patients under

the age of 21.

• >21 means that Prior Authorization is required for patients 21 years
• f age and older.
• PA means that Prior Authorization is required for all patients.
• Providers can access the dental fee schedule at

www.ctdssmap.com to determine which procedure codes require PA or PR.

• Providers should refer to the CTDHP Web site www.ctdhp.com

and access the provider manual to determine if a procedure complies with the Medical Services Policy.

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Prior Authorizations

• Electronic prior authorization or post procedure review

requests may be submitted electronically via the www.ctdhp.com provider Web portal.

• To upload a PA/PR request, follow the steps outlined

below:

• 1. Access the www.ctdhp.com Web site and click on

"Provider Partners.”

• 2. Enter your Billing NPI and Tax ID numbers in the

appropriate boxes and click on "Submit."

• 3. A new screen will appear, click on "Prior

Authorization Upload."

• 4. Follow instructions for prior authorization or post

procedure review requests.

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Prior Authorizations

• Hard copy submissions for the non-orthodontic services

that require PA or PR should be submitted to: CT Medicaid Prior-Authorizations C/O Dental Benefit Management, Inc. / CTDHP P.O. Box 40109 Philadelphia, PA 19106-0109

• Hard copy PA requests for orthodontic services should be

submitted to: Orthodontic Case Review C/O BeneCare Dental Plans 195 Scott Swamp Road, Suite 101 Farmington, CT 06032

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Prior Authorizations

• For any questions regarding PAs or to request an emergency

PA, call CTDHP Provider Relations and Services at:

• 1-888-445-6665 Monday through Friday, 8 a.m. to 5

p.m. (EST), excluding holidays * Please Note: Do not submit any PAs or PRs to HP or DSS, the PAs and PRs will be returned to your office!

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Prior Authorizations

• Allow fifteen (15) business days for the review, processing of

prior authorization and post procedure review requests.

• CTDHP will enter the information for the approved PAs and

PRs in HP’s system.

• Denied PA/PR requests will not be entered; however, the

provider will be informed via a written response.

• PA approval status may be verified via the CT Medical

Assistance Program Web site at www.ctdssmap.com.

• The Prior Authorization (PA) Search allows providers to

see if the PA or PR has been entered into the system prior to submitting their claims.

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Prior Authorizations Inquiry

• On the provider secure Web site www.ctdssmap.com, under

“prior authorization” select “prior authorization search”.

• Enter a client ID and click search to bring up prior

authorizations for a specific client.

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Prior Authorizations Inquiry PA Inquiry result

• You can see the procedure code that was approved,

authorized units/dollars, authorized effective/end dates, used units/dollars and available units/dollars.

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Program Limitations

Provider Bulletin 2012-38 “ Change of Dental Benefit Assignment by Dental Provider to Benefit Assignment by Client.”

• The benefit limitations for services delivered to all clients

changed from a provider based benefit assignment to a client based benefit assignment which mirrors commercial dental plan reimbursement. This took effect on November 1, 2012 for all clients.

• All dental providers who deliver services to clients should

check to ensure that each client is eligible to receive dental services by verifying the client’s eligibility status and dental history before performing any treatment on a client.

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Program Limitations

• To verify when a procedure was last performed on a client,

go to the www.CTDHP.com Web site and click on the link on the left hand side of the Home Page labeled "Provider Partners" then click on “Sign In”.

1) Choose the link labeled “Client Inquiry.” 2) Enter the client’s Medicaid ID number and date of birth and

click “Submit.”

3) The screen will return the client’s current eligibility status

for the date of the inquiry as well as a listing of all historical dental procedures performed on file for this client. The procedures reported go back to 2008. * It is important to ask clients about any recent dental visits as the claims history does not include claims yet to be submitted for services recently performed.

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Program Limitations

Once per calendar year vs. one time per 365 days.

• As of November 1, 2012 the frequency for services limited by

a one time per year benefit, are calculated by calendar year and not a rolling 365 days.

• If the dental service was provided in October 2013 and the

provider wants to provide the service again in May 2014, the system will allow payment for these services because the system evaluates the claims based on being performed and paid in a calendar year.

• When a client requires services more than the program

permits, the provider must request a prior authorization from CTDHP.

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Web Claim Inquiry

• At the “Claims” menu select “claim inquiry” to view claims

processed regardless of the submission method

• Search by:
• Internal Control Number (ICN)
• Client ID and date of service (no greater range than 93

days)

• Pending claims

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Web Claim Submission

Dental claims can be submitted through the secure Web site by signing into www.ctdssmap.com.

• Once on the secure site, select Dental from the claims

drop-down menu. Claim types that can be submitted through the secure Web site www.ctdssmap.com:

• Primary and Secondary/Third Party Liability (TPL) claims.
• Re-submission and adjustments if they are within timely

filing.

• Recoup/Void a claim at any time regardless of timely filing.

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Web Claim Submission

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Web Claim Submission

• If the provider is billing for a behavior management

procedure code (D9920) along with other dental services, they must bill the related diagnosis code (318-319) to the behavior management service in the diagnosis field. ***Please note these Diagnosis Codes will change with the ICD-10 implementation.

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Web Claim Submission with TPL

Required fields:

• Carrier Code – 3-digit carrier code identifying the other

insurance (OI) carrier.

• Paid Amount – Enter amount paid by the other insurance; if

denied enter zero.

• Paid Date - Enter the date the other insurance paid or

denied the claim.

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Web Claim Submission

Once you hit the submit button, the claim results are immediate.

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Web Claim Submission

Web Claim function buttons Paid claim Denied claim Suspended claim

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Frequent Claim Denials

EOB 261

“Tooth Number Missing”

EOB 262

“Tooth Number Invalid”

EOB 4211 “Tooth Number/Procedure Code Combination Invalid”

• A good reference for these denials is bulletin 2009-25 “Tooth

Numbers to be Used in Conjunction with Specified Procedure Codes”. And bulletin 2009-57 “Correction to Bulletin 2009-25 Updates to Requirements for Dental Claims Submission.”

• It informs dental providers about the proper tooth numbers to use

when submitting claims which involve CDT codes that require tooth numbers and/or letters.

• This bulletin also defines the proper format to use when submitting

claims which involve supernumerary teeth.

• Certain procedures have age restrictions on specified codes and

this bulletin informs dental providers of the age limitations that are included on the Medicaid Dental Fee schedule.

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Frequent Claim Denials

EOB 6148 “One restoration per tooth surface allowed per year”

• To avoid this error message, DSS recommends that

providers verify a client’s eligibility on the date of service prior to performing said service and the client’s claim history.

• To verify when a procedure was last performed on a client, go

to the www.CTDHP.com Web site and click on the link on the left hand side of the Home Page labeled "Provider Partners," next click on “Sign In”, and then “Client Inquiry.”

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Messages Archived

DSS and HP have started archiving RA Banner and Important Messages on the www.ctdssmap.com Web site. To access archived messages, providers need to access the Messages Archived page by selecting Messages Archived from the Information drop-down menu on the home page. RA Banner and Important Messages dated January 1, 2014 and forward are saved on the Web site and are available for review.

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ICD-10

ICD-10 Compliance Date

• On July 31, 2014, the U.S. Department of Health and Human

Services issued a rule finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. The rule also requires HIPAA covered entities to continue to use ICD-9 through September 30, 2015.

• The transition to ICD-10 is required for all providers, payers

and vendors.

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ICD-10

• ICD-10-CM: The clinical modification diagnosis classification

system was developed by the World Health Organization (WHO) and the National Center for Healthcare Statistics (NCHS) for use in all U.S. health care treatment settings. (The CM codes increase from 13,000 to 68,000-plus in the ICD-10- CM code set.)

• Currently, CMAP does not require a diagnosis code on dental

claims unless the procedure code is D9920 (Behavior Management). So majority of dental claims will not be affected by this transition.

• Do note – if you submit a diagnosis code on your claim, it will

be subject to ICD-10 editing. Also be aware of any requirement(s) to submit diagnosis code(s) when submitting for a prior authorization or writing a prescription.

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ICD-10

• ICD-10 codes must be used on all HIPAA transactions and

dental claims with dates of service (DOS) on or after the ICD- 10 implementation date.

• Provider Electronics Solutions (PES), the free software supplied

by HP to providers, will not support ICD-10 codes. Providers using PES are encouraged to transition to an alternate method

• f claim submission before October 1,2015. Web claim

submission is a user friendly tool available to our providers.

• Do make it a point to refer to the ICD-10 Implementation

Information Important Message from the home page of our Web site www.ctdssmap.com frequently to keep abreast with the most recent ICD-10 developments.

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Training Session Wrap Up

• Where to go for more information www.ctdssmap.com
• Important Messages and Provider Bulletins
• CTDHP Provider Relations and Network Support will assist

with PA, claim history and Provider Enrollment: Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays.

• 1-888-445-6665
• Client Services to assist clients in finding dentist.
• 1-855-283-3682
• HP Provider Assistance Center (PAC) to assist with claims:

Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays.

• 1-800-842-8440
• 1-800-688-0503 (EDI Help Desk)

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Time for Questions

Questions & Answers