2015 PREGNANT WOMEN BENEFIT OVERVIEW

Transcription

1 2015 PREGNANT WOMEN BENEFIT OVERVIEW 1

2 Training Objectives Enrollees Eligibility and Effective Date Benefits for Pregnant Women Documentation Requirements for Pregnant Women Benefits (Claims Submissions) Verifying Eligibility for Pregnant Benefit Recommendations of Treatment during each Trimester Medication Recommendations during and after Pregnancy Online Learning Center-Free CEU s Virginia (VA) Provider Relations Team for the Smiles For Children (SFC) Program 2

3 Medicaid Pregnant Women Over 21 Enrollee Eligibility Effective date March 1, 2015 Pregnant women in Medicaid and FAMIS MOMS who are 21 years of age and older are eligible to receive appropriate dental benefits (excluding Orthodontia) through Virginia s dental program, Smiles For Children (SFC) DentaQuest uses the 12-digit Medicaid ID number as the enrollee ID Number for the Pregnant Women Benefit Dental benefits for pregnant women who are 21 years of age and older will be discontinued at the end of the month following their 60th day postpartum 3

4 Benefits for Pregnant Women Enrollees Coverage for pregnant women will include the following: Diagnostic Preventive Restorative Endodontics Periodontics Prosthodontics- both removable and fixed (crowns, bridges, partials and dentures) Oral surgery (extractions and other oral surgeries), and; Adjunctive general services (all covered services that do not fall into specific dental categories) Covered services are listed in Exhibit C of the ORM. The updated ORM will be available via the Provider Web Portal (PWP) under related documents by March 1,

5 Documentation Required for Reimbursement Prepayment review will be conducted on all claims and appropriate documentation must include: Narrative indicating member is pregnant with estimated date of delivery (must be noted in box 35 of ADA claim form) Narrative demonstrating medical necessity for those services where additional documentation is required for review (i.e. diagnostic x-rays, perio charting) Fees are reimbursed in accordance with the SFC Schedule of Allowable Fees as reflected in the Provider Agreement 5

6 Verifying Member Eligibility via PWP Select a valid service office and dentist combination from the Select a Location and Provider drop-down list. Enter the member (s) for whom you want to perform an eligibility search: NOTE: All required fields are marked with a red asterisk (*). a. Enter the service date or select it from the pop-up calendar in the Service Date field. b. Enter the DOB (date of birth) or select it from the pop-up calendar in the DOB field. c. You must include either the member number OR the member s last name and part of the first name: Type in the member number in the Member Number field or Type in the member s last name and part of the first name in the Member Last Name and Member First Name fields. d. Repeat this step for each member you are searching. 6

7 Members Active with Pregnant Women Benefit The member will show active or ineligible on the member eligibility page, click on the member list for the member For members showing active, the member detail page will list member name, DOB, and Plan (VA SFC Pregnant Women) Members may be enrolled in the VA SFC Over 21 plan or VA SFC Pregnant Women plan. If a member is enrolled in the VA SFC over 21 plan and is pregnant she is entitled to the enhanced pregnancy benefit. 7

8 Guidelines/Recommendations During First Trimester (conception to 14 th week) Educate the member about maternal oral changes during pregnancy Emphasize strict oral hygiene instructions and plaque control Limit dental treatment (services) to periodontal prophy and emergency treatment only Avoid routine radiographs Guideline Resources: CDAfoundation.org (California Dental Association), National Maternal and Child Oral Health Resource Center, and American College of Obstetricians and Gynecologists 8

9 Treatment Recommendations During Second Trimester (14 th to 28 th week) Review oral hygiene instructions and plaque control Scaling, polishing and curettage may be preformed if necessary Control of active oral diseases, if any Elective dental care is safe Avoid routine radiographs, use selectively Guideline Resources: CDAfoundation.org (California Dental Association), National Maternal and Child Oral Health Resource Center, and American College of Obstetricians and Gynecologists 9

10 Guidelines During Third Trimester (29 th week to birth) Oral Hygiene Instructions and Plaque Control Scaling, polishing and curettage may be performed if necessary Avoid elective dental procedures during the second half of the third trimester Avoid routine radiographs, use selectively and ALWAYS use a shield Guideline Resources: CDAfoundation.org (California Dental Association), National Maternal and Child Oral Health Resource Center, and American College of Obstetricians and Gynecologists 10

11 Medication Management Guidelines Guideline Resources: CDAfoundation.org (California Dental Association), National Maternal and Child Oral Health Resource Center, and American College of Obstetricians and Gynecologists 11

12 FREE CEUs: DENTAQUEST INSTITUTE 1. Go to: to open the Online Learning Center. 2. Click the Register button to sign up and create your user name and password. 3. Upon registration you will have access to all of the learning resources available. 12

13 ONLINE LEARNING CENTER Watch our Leader Profile videos to hear from oral health leaders who are practicing prevention and disease management. Create a Profile on our CONNECT Social Media page and begin to network with practitioners and thought leaders around the country. Browse the Resource Library to view webinars, access valuable web links and read white papers. 13

14 DISEASE MANAGEMENT SERIES- FREE CEUs This learning series consists of seven 30- to 40-minute online learning modules designed for dental directors and dental practice managers. The modules provide an overview of the main components of practice management for a Safety Net Dental Program. You will receive one CE credit for every two courses that you successfully complete. All CEU credits are FREE! 14

15 Module 3 Dental Caries Management: Perinatal You'll see how you can apply the preventive approach to perinatal oral health care. This module will cover the current science, policies, clinical guidelines, and opportunities for providing improved care. 15

16 DentaQuest Provider Relations Team Bridget Hengle Provider Relations Representative Toll-Free: Fax: Waradah K. Eargle Providers Relation Representative Toll-Free: Fax:

17 THANK YOU FOR PROVIDING DENTAL CARE TO THE SMILES FOR CHILDREN MEMBERS IN YOUR COMMUNITY. WE GREATLY APPRECIATE YOUR SUPPORT! 17