INDIANA ROUNDUP PROGRAM UPDATES FOR OUR INDIANA DENTISTS VOL 1 December 2016 IN THIS ISSUE:

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1 INDIANA ROUNDUP PROGRAM UPDATES FOR OUR INDIANA DENTISTS IN THIS ISSUE: Welcome from DentaQuest Indiana s Director of Managed Care Introducing Dr. Steven Barefoot, Dental Director DentaQuest Provider Engagement Representative territories DentaQuest s role in managed care IHCP provider enrollment and notifications Patient eligibility verification Hoosier Healthwise transitions from fee-forservice to managed care Contracting with DentaQuest MHS Indiana transitions their dental services in-house Cultural competency, non-discrimination, and permitted billing of Medicaid patients Keeping your practice open to new patients New CDT codes ADA claim form for EPSDT New provider portal Healthy Indiana Plan (HIP) and dental coverage Orthodontic authorization requirements Payment recoupments and audits Updating provider information A timely filing reminder Electronic claim submission and EFT Submitting claims for dentures after extractions Claim submission information Testimonial First, I would like to thank DentaQuest for entering the Indiana market. Having worked with DentaQuest in other States where Familia is present over the past 8 years, we have always enjoyed a great working relationship with DentaQuest. It all starts at the top going all the way to the field reps. I believe one of the main reasons for DentaQuest s success is the fact they hire the right people for the job. Overall, we value Cindy as our representative in all Indiana Clinics. Familia Dental would like to thank DentaQuest and Cindy Cobb for excellent and continuous work. As Familia Dental grows, we hope to continue our collaboration with DentaQuest for years to come. Kayvan Azar VP of Recruitment Familia Dental AINPEC December 2016, APP0287 (12/16)

2 WELCOME A message from Lanaya Sandberg, Director of Managed Care at DentaQuest Indiana I joined the DentaQuest team in June of 2016, and the past few months have been quite fast paced. My team and I have worked to establish and maintain strong relationships with our provider network, and are preparing to launch a third program, Hoosier Healthwise, in January As DentaQuest s Director of Managed Care, I look forward to continuing the momentum of building a valuable partnership with you. Our team of Provider Engagement Representatives are dedicated to answering your inquiries and questions, and keeping you apprised of relevant updates. Each and every in-network provider has a committed Provider Engagement Representative. Please outreach to your Provider Engagement Representative whenever you would like to schedule an office visit or require assistance. Additionally, we have added a Dental Director, Stephen Barefoot, DDS, who is responsible for providing clinical support for provider outreach and education. As an in-network provider, we are devoted to communicating information and updates to you. Through our newsletters, s, fax blasts, provider portal, and webinars, we will broadcast news updates with you. If you have any inquiries, please contact your Provider Engagement Representative. DentaQuest has recently refreshed its values, and I think it is important to share these with our provider community as this represents who we are and what we stand for here at DentaQuest. These values are the DNA of our culture and put providers, members, customers, and each other at the center of everything we do.

3 We thank you for welcoming DentaQuest into your communities, uniting with us to serve your patients and providing dental care to members. DentaQuest s mission is to improve the oral health of all, and I could not be more excited to be a part of the team and work to support this mission. Respectfully, Lanaya Sandberg Director of Managed Care DentaQuest

4 INTRODUCING DR. STEVEN BAREFOOT, DDS DentaQuest would like to welcome Dr. Steven Barefoot, DDS to the Indiana team! He is a graduate of Indiana University Bloomington and the IU School of Dentistry. In his role as Dental Director for Indiana, he will focus on interactions with providers and will provide clinical input and perspective to the DentaQuest Indiana Provider Engagement team as we strive to provide the highest level of support to the providers in our network, and focus on our common goal to improve the oral health of all. DENTAQUEST S ROLE IN ADMINISTERING THE INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION S PROGRAMS The Indiana Family and Social Services Administration (FSSA) was established to consolidate and better integrate the delivery of human services by State government. FSSA is dedicated to helping Hoosiers live productive, safe, and healthy lives. The Office of Medicaid Policy and Planning (OMPP) administers health coverage programs including the Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise, and other Indiana Medicaid programs. OMPP processes applications and determines the eligibility of individuals and families for its Medicaid programs, along with determining the associated fee schedules. FSSA has directly contracted with Anthem Blue Cross and Blue Shield (Anthem) and MDwise, Inc. to serve its HIP, Hoosier Care Connect, and Hoosier Healthwise beneficiaries in Indiana. Anthem and MDwise, Inc. have subsequently contracted with DentaQuest Indiana to administer dental benefits. DentaQuest s primary role is to ensure that claims received from providers accurately reflect covered services, and are consistent with the benefits defined by OMPP.

5 DENTAQUEST S PROVIDER ENGAGEMENT REPRESENTATIVE TERRITORIES INDIANA HEALTH COVERAGE PROGRAM (IHCP) PROVIDER ENROLLMENT OMPP requires that all provider types contracting with Managed Care Entities (MCEs), including Anthem and MDwise, or their chosen dental benefits administrator, must enroll in OMPP s IHCP for HIP, Hoosier Care

6 Connect, and Hoosier Healthwise programs. IHCP is used by all Medicaid program providers doing business in the State of Indiana and providers are required to revalidate at intervals not to exceed every five (5) years. To enroll in OMPP s IHCP, please contact them via telephone at or access their website at: IHCP NOTIFICATIONS OMPP frequently distributes IHCP bulletins highlighting changes, updates, and requirements. To sign up to receive IHCP notifications, visit the following link: PATIENT ELIGIBILITY VERIFICATION As provided in DentaQuest s Office Reference Manual, providers are encouraged to check patient eligibility through the IHCP eligibility check process, Web interchange, at: The enrollment information contained within Web interchange will be considered the source of truth. When verifying a patient s eligibility, it is important to check based on the date of service, as Medicaid eligibility is subject to change, at OMPP s sole discretion. Furthermore, OMPP may make retroactive eligibility determinations, including, but not limited to, the following situations: changes in a beneficiary s modified adjusted gross income, changes in State of residency, age limitations, pregnancy or parental status, or an act of fraud. DentaQuest does not have the authority to overturn an appealed claim determination based on eligibility. HOOSIER HEALTHWISE TRANSITIONS FROM FEE-FOR-SERVICE TO MANAGED CARE OMPP is expanding its IHCP by transitioning the Hoosier Healthwise dental program from fee-for-service to managed care. Who: Hoosier Healthwise is a program sponsored by OMPP covering children up to the age of 19, former foster children up to the age of 25, and low-income parents and caretakers of children under the age of 18, and pregnant women.

7 What: Hoosier Healthwise dental benefits are transitioning from fee-for-service to managed care. MDwise, Inc. and Anthem are MCEs proudly serving Hoosier Healthwise members. When: This transition is expected to take place January 1, Where: This transition applies Statewide. Why: Hoosier Healthwise dental benefits are transitioning with the goals of improving quality and accessibility, creating greater accountability, and reducing costs. CONTRACTING WITH DENTAQUEST To contract with DentaQuest for the HIP, Hoosier Care Connect, and Hoosier Healthwise programs, please contact a DentaQuest Provider Engagement Representative or visit DentaQuest Indiana s website at: Scroll down towards the bottom of the webpage to where it indicates Join Our Network. Until providers have enrolled in OMPP s IHCP, DentaQuest is unable to regard the provider as in network and is prohibited from making payment for services rendered. DentaQuest currently maintains an open network, and, therefore, is always interested in contracting with dental providers, including minority business enterprise and women business enterprise (MBE/WBE) providers. MANAGED HEALTH SERVICES (MHS) INDIANA TRANSITIONS THEIR DENTAL SERVICES IN-HOUSE Effective October 1, 2016, DentaQuest will no longer administer dental benefits for MHS Indiana for the HIP and Hoosier Care Connect programs. Dental Health and Wellness, a sister company of MHS, will be managing all dental benefits for MHS. At this time, there will be no other changes to the HIP and Hoosier Care Connect programs. Should you have any questions, please contact Dental Health and Wellness at CULTURAL COMPETENCY We live in a diverse nation, bringing together people of many different cultures. Culture influences a person s perspective, values, and behaviors about health and well-being. It is important to understand social and cultural differences in delivering quality dental services. To learn more about cultural competency issues and how you can get involved in Indiana, please call the Indiana State Department of Health, Office of Cultural Diversity and

8 Enrichment at or or visit the following website: NON-DISCRIMINATION As a healthcare provider, you have a responsibility to not differentiate or discriminate in providing covered services to patients because of race, color, religion, national origin, ancestry age, sex, marital status, sexual orientation, physical, sensory or mental handicap, socioeconomic status, or participation in publicly financed health care programs. Providers are to render covered services to patients in the same location, in the same manner, in accordance with the same standards, and within the same time availability regardless of source of payment. PERMITTED BILLING OF MEDICAID PATIENTS Providers may bill or charge DentaQuest patients only in the following circumstances: (a) applicable copayments or cost sharing, if any; (b) for services that are not covered services only if: (i) the patient s benefit coverage provides and/or DentaQuest confirms that the specific services are not covered; (ii) the patient was advised, in writing, prior to the services being rendered that the specific services may not be covered services; and (iii) the patient agreed, in writing, to pay for such services after being so advised. THE IMPORTANCE OF KEEPING YOUR PRACTICE OPEN TO NEW PATIENTS* A significant component of the Patient Protection and Affordable Care Act (PPACA) is the expansion of Medicaid eligibility with individuals and families who earn incomes up to 133 percent of the federal poverty level are now eligible for Medicaid coverage. One of the goals of Medicaid expansion is to provide health insurance coverage to more Americans and Hoosiers. In reaching this goal, there are obstacles, such as low reimbursement rates, that make Medicaid patients less attractive to practices. At DentaQuest, we believe that serving Medicaid beneficiaries is a head and heart business. We have heard from practices wondering if they might be better off not accepting Medicaid patients altogether. Before making this decision, we suggest that there are a few questions worthy of asking: 1. Assess the ethical implications Are you uncomfortable with the notion of excluding low-income patients from your practice?

9 Do your ethical concerns outweigh your concerns with low reimbursement and problems presented by Medicaid patients? 2. Evaluate your options for management How many Medicaid patients can you see and still breakeven? 3. Consider a dental hygienist, dental therapist, or other midlevel provider 4. Ascertain how your practice will fill its schedule Is there adequate demand in your community to replace the Medicaid patients you will lose? Do you have the capacity and resources to recruit new patients? 5. Pinpoint issues posed by Medicaid patients Do you have patients who miss or are late to their appointments? Do you have noncompliant or challenging patients? Let your DentaQuest Provider Engagement Representative know and they can work internally with Member Services to educate the patient. * Paraphrased from 5 Questions to Ask Before You Stop Accepting Medicaid Patients by Melissa McCormack NEW CDT 2017 IS HERE! The American Dental Association (ADA) has released its 2017 Code on Dental Procedures and Nomenclature (CDT Code), including new, revised, and deleted procedure codes. To learn more, please refer to the ADA s website at: It is important to note that while the ADA may update its CDT Codes, DentaQuest will continue to pay according to the published CDT Codes and associated fees established by the IHCP, and updated from time-to-time, which are available at: ADA CLAIM FORM FOR EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) Item 1 in the standard ADA claim form includes a checkbox for EPSDT. By checking this box, you are attesting that it is your professional opinion that a not-otherwise-covered dental service should be covered under EPSDT/Healthwatch based on medical necessity. However, checking this box does not necessarily mean the service will be covered, and is, therefore, not a guarantee of payment. Instead, the claim or authorization and associated documentation will be reviewed by DentaQuest in accordance with guidelines published in

10 DentaQuest s Office Reference Manual available at the following link: NEW PROVIDER PORTAL Participating providers have access to a powerful new provider portal that will allow you to easily support your patients and manage your practice all right from your desk. This new provider portal provides easy administration for you, simplistic support for your patients, and allows you to communicate more efficiently with DentaQuest. The provider web portal is a secure website that allows DentaQuest providers to perform selfservice functions 24 hours a day, seven days a week. Registration is easy. You can register online at: Contact your DentaQuest Provider Engagement Representative if you would like to schedule a personalized registration and training meeting. For any technical support or if you have already registered, but do not remember your username or password, call DentaQuest s Customer Service at HIP AND DENTAL COVERAGE HIP is an affordable health plan for low-income adult Hoosiers between the ages of 19 and 64. There are different types of benefit packages, and include four levels of dental coverage, as follows: 1. HIP Basic- for 19 and 20 year olds 2. HIP Plus 3. HIP State Plan Basic*- members have a $4 outpatient copay per service category and HIP State Plan Plus * HIP State Plan Basic and HIP State Plan Plus have the same dental benefit coverage.

11 AUTHORIZATION REQUIREMENTS FOR ORTHODONTIC SERVICES OMPP has defined authorization criteria for orthodontic services. To be considered eligible for orthodontics, medical necessity must be first established by the patient presenting with a medical condition that falls within one (1) of three (3) State-defined categories. OMPP does not recognize a malocclusion that is not comorbid with one (1) of the listed medical conditions as sufficient to qualify for orthodontic procedures. Category I and Category II consist of specific genetic disorders and syndromes such as Cleidocranial Dysplasia or Fetal Alcohol Syndrome. Patients in Category III must be diagnosed with a severe, atypical craniofacial skeletal pattern. Patients that are in Category II and Category III must also demonstrate a moderate or severe malocclusion, as defined by specific, State guidelines. Complete criteria can be found in DentaQuest s Office Reference Manual made available at the following link: DENTAQUEST PAYMENT RECOUPMENTS AND AUDITS DentaQuest recovers payments, with just cause, and in accordance with State law. The following are examples of when DentaQuest may recover payments: When services rendered are non-covered; If a provider was not credentialed with DentaQuest as of the date of service or did not pass DentaQuest s re-credentialing; If a provider was not enrolled in the IHCP as of the date of service; If a provider fails to submit a clean claim timely; If a provider commits fraud; and A member complaint or grievance that results in a subsequent investigation for the purposes of quality assessment, utilization, and quality improvement. DentaQuest can perform retrospective review to identify if services were medically appropriate. As provided in DentaQuest s Office Reference Manual, providers have the right to submit an appeal.

12 UPDATING PROVIDER INFORMATION It is important for DentaQuest to keep our provider network information up-to-date, which allows DentaQuest to accurately generate provider directories, process claims, and communicate with our network of providers. Providers must notify DentaQuest, in writing, with at least thirty (30) days advance notice of changes, such as: Practice name change A change in practice address, phone, or fax numbers New office site location When a provider joins or leaves the practice Send changes to: StandardUpdates@dentaquest.com Fax: TIMELY FILING REMINDER DentaQuest providers shall submit claims for covered services to DentaQuest within ninety (90) days of the performance of services. For more details, please reference your DentaQuest LLC Dental Provider Service Agreement. To request a copy of your agreement for your records, please contact your DentaQuest Provider Engagement Representative. ELECTRONIC CLAIM SUBMISSION AND ELECTRONIC FUNDS TRANSFER (EFT) DentaQuest encourages its providers to submit claims electronically and signup for EFT, and doing so provides numerous benefits, including lowering outstanding receivables, quicker notification of claim receipt, status, and payment, improving cash flow, eliminating costs associated with mailings, reducing time spent on tracking and following up, and reducing clerical paperwork. Once a provider has become credentialed with DentaQuest, they are automatically enrolled in electronic submission of claims. To learn more, please contact your DentaQuest Provider Engagement Representative. SUBMIT CLAIMS FOR DENTURES AFTER EXTRACTIONS DentaQuest s Office Reference Manual provides that all prosthetic appliances shall be inserted in the mouth and adjusted before claims are submitted for payment. At a minimum, this means that a claim for a removable prosthetic appliance should never be submitted before the seat date for any extractions necessary for the

13 placement of the prosthesis. This claim submission requirement is also applicable to immediate dentures since it is anticipated that adjustments to immediate dentures will be required after the seat date of the extractions and initial denture placement. CLAIM SUBMISSION INFORMATION New and Corrected Claims: DentaQuest PO Box 2906 Milwaukee, Wisconsin Overpayment Checks: DentaQuest PO Box 2906 Milwaukee, Wisconsin Claim Reconsiderations: DentaQuest-Appeals PO Box 2906 Milwaukee, Wisconsin Prior Authorizations: DentaQuest- Prior Authorizations PO Box 2906 Milwaukee, Wisconsin Phone: Contact DentaQuest s Customer Service at Fax: A standard ADA Dental Claim form* to In box 1, check Request for Predetermination/Preauthorization. If the request is urgent, in box 35, under Remarks, indicate such. *A copy of the ADA dental claim form can be found by accessing the following link: