Agenda. Understanding the Office Reference Manual (ORM) Most Common Denial Reasons and Codes. Definition of Medical Necessity

Transcription

1 Best Practices 2018

2 Agenda Understanding the Office Reference Manual (ORM) Most Common Denial Reasons and Codes Definition of Medical Necessity Anesthesia Prior Authorization Process Effective July 1, 2017 Clinical Criteria CHIP Exceeding $564 Benefit Max Narratives X-rays / Photos Appeals Process Web Portal 2 Questions

3 Office Reference Manual (ORM) The Office Reference Manual (ORM) is located on the portal and on 3

4 Top 5 Most Common Denial Reasons Clinical CHIP 1. No narrative or supporting documentation for exceeding the $564 maximum. Extractions 2. Submitting for a higher code than documentation supports. For example, D7240 for a soft tissue impaction. Crowns 3. Tooth does not have extensive decay on multiple services or moderate cuspal involvement 4. No pre-op radiograph provided. Pre-op and post-op radiographs are required Third molar extractions 5. Provider does not submit a tooth specific narrative, the notes are generic or a template used for every prior auth. 4

5 Top 5 Most Common Denial Reasons Administrative 1. Service exceeds benefit limitations or maximum benefit allowance 2. Submitting provider is not the member s Primary Care Dentist 3. This procedure is a duplicate of a service previously processed 4. Patient is not eligible for program 5. This procedure has been submitted after the timely filing limit 5

6 Medical Necessity Medically necessary is defined in the Texas Administrative Code (TAC) Rule

7 Pre-payment Review vs. Prior Authorization Covered Dental Services that indicate Yes in the Review Required column will be subject to retrospective pre-payment review. These procedures can be rendered before determination of medical necessity but require submission of proper documentation (as indicated in the Documentation Required column) with the claim form that supports medical necessity. As an option, services that indicate Yes in the Review Required column can also be submitted for prior authorization prior to rendering the services. 7

8 Anesthesia Prior Authorization Process Effective July 1, 2017 Prior Authorization Criteria Requests for prior authorization must include, but are not limited to, the following client-specific documents and information: A completed Criteria for Dental Therapy Under General Anesthesia form A completed Prior Authorization Claim Form. This must include CDT code(s) for all procedures to be performed and D9223 or D9500 (a DentaQuest specific code that indicates Medical Anesthesia Services) based on place of service and anesthesiologist type Location where the procedure(s) will be performed (office or outpatient) Tentative date of service if outpatient request or in office using a medical anesthesiologist Narrative unique to the client, detailing reasons for the proposed level of anesthesia (indicate procedure code D9223 or D9500). The narrative must include history of prior treatment, failed attempts at other levels of sedation, behavior in the dental chair, proposed restorative treatment (tooth ID and surfaces), urgent need to provide comprehensive dental treatment based on extent of diagnosed dental caries, and any relevant medical condition(s). Diagnostic quality radiographs or photographs When appropriate radiographs or photographs cannot be taken prior to general anesthesia, the narrative must support the reasons for an inability to perform diagnostic services. For these special cases that receive authorization, diagnostic quality radiographs or photographs will be required for payment and will be reviewed by the DentaQuest Dental Director. The current process of scoring 22 points on the Criteria for Dental Therapy Under General Anesthesia form does not guarantee authorization or reimbursement for clients who are six years of age and younger. Note: In cases of an emergency medical condition, accident, or trauma, prior authorization is not necessary. However, a narrative and appropriate pre- and post-treatment radiographs or photographs must be submitted with the claim, which will be reviewed by the DentaQuest Dental Director. A copy of the Criteria for Dental Therapy under General Anesthesia form must be maintained in the client s dental record. The client s dental record must be available for review by representatives of the Health and Human Services Commission (HHSC) or its designee. 8

9 Anesthesia Prior Authorization Process Effective July 1, 2017 Dental Therapy under General Anesthesia - In Office 1. Treating Dentist using Dental Anesthesiologist Is responsible for obtaining prior authorization from DentaQuest and is responsible for providing the anesthesia prior authorization information to the dental anesthesiologist Submits one D9223 and CDT code(s) that will be performed under general anesthesia for prior authorization DentaQuest will determine medical necessity of the general anesthesia based on the submitted treatment plan and required documentation DentaQuest will notify the treating dentist of the determination via a Provider Determination Letter (PDL). For services that are approved, the treating dentist would then provide a copy of the PDL to the dental anesthesiologist. Code D9223 will indicate the DentaQuest determination and will be either approved or denied. While we are reviewing the necessity of the general anesthesia on the overall treatment plan, certain services on the PDL will indicate Service Not Reviewed if they do not typically require authorization under DentaQuest policy. Failure to submit per Prior Authorization Criteria as outlined above will result in a denial. See example below, indicating the anesthesia service (D9223) has been approved. Dental Anesthesiologist Upon completion of the approved services, the dental anesthesiologist will submit claims to DentaQuest The DentaQuest approved authorization number from treating dentist must be in Box 35 of the claims form or in the notes section of the portal Must submit appropriate units of D9223 with supporting documentation Must have a current level 4 permit Treating Dentist Upon completion of the approved services, the treating dentist will submit therapeutic services rendered to DentaQuest. 9

10 Anesthesia Prior Authorization Process Effective July 1, Treating Dentist using Medical Anesthesiologist Is responsible for obtaining prior authorization from DentaQuest and is responsible for providing the anesthesia prior authorization information to the medical anesthesiologist Submits D9500 and CDT code(s) that will be performed under general anesthesia for prior authorization DentaQuest will determine medical necessity of the general anesthesia based on the submitted treatment plan and required documentation. DentaQuest will notify the treating dentist of the determination via a Provider Determination Letter (PDL). For anesthesia that is approved, the treating dentist would then provide a copy of the PDL to the medical anesthesiologist. Code D9500 will indicate the DentaQuest determination and will be either approved or denied. While we are reviewing the necessity of the general anesthesia on the overall treatment plan, certain services on the PDL will indicate Service Not Reviewed if they do not typically require authorization under DentaQuest policy. Failure to submit per Prior Authorization Criteria as outlined above will result in a denial. See example below, indicating the medical anesthesia service (D9500) has been approved. Medical Anesthesiologist Is responsible for submitting a separate prior authorization request to the member s MCO along with the approved DentaQuest PDL The MCO reviews submitted documentation from DentaQuest to determine whether medical anesthesia is approved or denied Upon completion of the approved services, the medical anesthesiologist will submit claims to the member s MCO using the appropriate CPT code(s) Treating Dentist Upon completion of the approved services, the treating dentist will submit therapeutic services rendered to DentaQuest DentaQuest. DentaQuest is a registered trademark of DentaQuest, LLC ( DentaQuest ). All rights reserved.

11 Anesthesia Prior Authorization Process Effective July 1, 2017 Dental Therapy under General Anesthesia Outpatient Treating Dentist Is responsible for obtaining prior authorization from DentaQuest and is responsible for providing the anesthesia prior authorization information to the medical anesthesiologist and / or facility Submits code D9500 and CDT code(s) that will be performed under general anesthesia for prior authorization The prior authorization request must indicate tentative procedure date(s) of service and facility name in Box 35 (remarks) of the ADA claim form Place of service must also be indicated in Box 38 of the ADA claim form DentaQuest will determine medical necessity of the general anesthesia based on the submitted treatment plan and required documentation DentaQuest will notify the treating dentist of the determination via a Provider Determination Letter (PDL). For anesthesia that is approved, the treating dentist would then provide a copy of the PDL to the medical anesthesiologist and / or facility. Code D9500 will indicate the DentaQuest determination for Medical Anesthesia Services Medical Anesthesiologist and / or Facility Is responsible for submitting a separate prior authorization request to the member s MCO along with the approved DentaQuest PDL The MCO reviews submitted documentation from DentaQuest to determine whether medical anesthesia and/or facility is approved or denied Upon completion of the approved services, the medical anesthesiologist and / or facility will submit claims to the member s MCO using the appropriate CPT code(s) Treating Dentist Upon completion of the approved services, the treating dentist will submit therapeutic services rendered to DentaQuest Please remember that the provider who submits the authorization for the dental therapeutic services must be the provider that performs the services. If the authorized provider does not perform the service, claims will deny. In the event the authorized provider is unable to perform the services, DentaQuest must be notified to update the authorization prior to the services being performed. This is not applicable to the anesthesiologist. 11

12 Anesthesia Prior Authorization Process Effective July 1, 2017 Treating Dentist using Dental Anesthesiologist Is responsible for obtaining prior authorization from DentaQuest and is responsible for providing the anesthesia prior authorization information to the dental anesthesiologist Submits one D9223 and CDT code(s) that will be performed under general anesthesia for prior authorization DentaQuest will determine medical necessity of the general anesthesia based on the submitted treatment plan and required documentation DentaQuest will notify the treating dentist of the determination via a Provider Determination Letter (PDL). For services that are approved, the treating dentist would then provide a copy of the PDL to the dental anesthesiologist. Code D9223 will indicate the DentaQuest determination and will be either approved or denied. While we are reviewing the necessity of the general anesthesia on the overall treatment plan, certain services on the PDL will indicate Service Not Reviewed if they do not typically require authorization under DentaQuest policy. Failure to submit per Prior Authorization Criteria as outlined above will result in a denial. See example below, indicating the anesthesia service (D9223) has been approved. The prior authorization request must indicate tentative procedure date(s) of service and facility name in Box 35 (remarks) of the ADA claim form Place of service must also be indicated in Box 38 of the ADA claim form Dental Anesthesiologist Upon completion of the approved services, the dental anesthesiologist will submit claims to DentaQuest The DentaQuest approved authorization number from treating dentist must be in Box 35 of the claims form or in the notes section of the portal Must submit appropriate units of D9223 with supporting documentation Must have a current level 4 permit Treating Dentist Upon completion of the approved services, the treating dentist will submit therapeutic services rendered to DentaQuest 12

13 Texas Administrative Code (TAC) Records and Sedation Requirements The Texas Administrative Code provides specific rules that apply to dental record documentation requirements and required sedation information. Please refer to the following: 22 Tex. Admin. Code Records of the Dentist 22 Tex. Admin Codes Sedation / Anesthesia Permit 22 Tex. Admin Codes Deep Sedation and Anesthesia 22 Tex. Admin Codes Portability 22 Tex. Admin Codes Use of General Anesthetic Agents 13

14 CLINICAL CRITERIA

15 Dental Extractions Documentation needed for pre-payment review or prior authorization: Appropriate radiographs showing clearly the adjacent and opposing teeth should be submitted for authorization review: periapicals or panorex. Treatment rendered under emergency conditions, when authorization is not possible, will still require that appropriate radiographs showing clearly the adjacent and opposing teeth be submitted with the claim for review for payment. Narrative demonstrating medical necessity. 15

16 Criteria The prophylactic removal of asymptomatic teeth (i.e. third molars) or teeth exhibiting no overt clinical pathology is subject to consultant review. The removal of primary teeth whose exfoliation is imminent does not meet criteria. Alveoloplasty (code D7310) in conjunction with four or more extractions in the same quadrant will be covered subject to consultant review. 16

17 Impaction Denials 17

18 Impaction Approvals Aberrant Position/Pathology 18

19 Endodontic Documentation needed for pre-payment review or prior authorization: Sufficient and appropriate radiographs showing clearly the adjacent and opposing teeth and a pre-operative radiograph of the tooth to be treated; periapicals or panorex. A dated post-operative radiograph must be submitted for review for payment. Treatment rendered under emergency conditions, when authorization is not possible, will still require that appropriate radiographs clearly show: The adjacent and opposing teeth. Pre-operative radiograph and dated post-operative radiograph of the tooth treated. In cases where pathology is not apparent, a written narrative justifying treatment is required. 19

20 Criteria Root canal therapy is performed in order to maintain teeth that have been damaged through trauma or carious exposure. Root canal therapy must meet the following criteria: Fill should be sufficiently close to the anatomical apex to ensure that an apical seal is achieved. Fill must be properly condensed/obturated. Filling material does not extend excessively beyond the apex. 20

21 will not meet criteria Gross periapical or periodontal pathosis is demonstrated radiographically (caries subcrestal or to the furcation, deeming the tooth non-restorable). The general oral condition does not justify root canal therapy due to loss of arch integrity. Root canal therapy is for third molars, unless they are an abutment for a partial denture. Tooth does not demonstrate 50% bone support. Root canal therapy is in anticipation of placement of an overdenture. A filling material not accepted by the Federal Food and Drug Administration (e.g. Sargenti filling material) is used. 21

22 Other Considerations Root canal therapy for permanent teeth includes diagnosis, extirpation of the pulp, shaping and enlarging the canals, temporary fillings, filling and obturation of root canal(s), and progress radiographs, including a root canal fill radiograph. In cases where the root canal filling does not meet DentaQuest s treatment standards, DentaQuest can require the procedure to be redone at no additional cost. Any reimbursement already made for an inadequate service may be recouped after DentaQuest reviews the circumstances. 22

23 Stainless Steel Crowns Documentation needed for pre-payment review or prior authorization: Appropriate radiographs showing clearly the adjacent and opposing teeth should be submitted for authorization review: bitewings, periapicals or panorex. Treatment rendered under emergency conditions, when authorization is not possible, will still require that appropriate radiographs showing clearly the adjacent and opposing teeth be submitted with the claim for review for payment. Narrative demonstrating medical necessity if radiographs are not available. 23

24 Criteria In general, criteria for stainless steel crowns will be met only for teeth needing multisurface restorations where amalgams and other materials have a poor prognosis. Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma, and should involve four or more surfaces and two or more cusps. Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma, and should involve three or more surfaces and at least one cusp. Permanent anterior teeth must have pathologic destruction to the tooth by caries or trauma, and should involve four or more surfaces and at least 50% of the incisal edge. Primary molars must have pathologic destruction to the tooth by caries or trauma, and should involve two or more surfaces or substantial occlusal decay resulting in an enamel shell. 24

25 Criteria crown following root canal Request should include a dated post-endodontic periapical radiograph. Tooth should be filled sufficiently close to the radiological apex to ensure that an apical seal is achieved. The filling must be properly condensed/obturated. Filling material does not extend excessively beyond the apex. 25

26 CRITERIA CROWN FOLLOWING ROOT CANAL To meet criteria, a crown must be opposed by a tooth or denture in the opposite arch or be an abutment for a partial denture The patient must be free from active and advanced periodontal disease. The fee for crowns includes the temporary crown that is placed on the prepared tooth and worn while the permanent crown is being fabricated for permanent anterior teeth. Payment for crowns must be billed on seat date and not prep date. Cast Crowns on permanent teeth are expected to last, at a minimum, five years. 26

27 Will not meet criteria A lesser means of restoration is possible Tooth has subosseous and/or furcation caries Tooth has advanced periodontal disease Tooth is a primary tooth Crowns are being planned to alter vertical dimension 27

28 Periodontal Treatment Documentation needed for pre-payment review or prior authorization: Radiographs periapicals or bitewings preferred Complete periodontal charting with AAP case type Treatment plan 28

29 Criteria A minimum of four teeth affected in the quadrant. Periodontal charting indicating abnormal pocket depths in multiple sites. Additionally, at least one of the following must be present: Radiographic evidence of root surface calculus. Radiographic evidence of moderate to severs loss of bone support. 29

30 30 D4341 Denials

31 D4341 Approvals 31

32 ADMINISTRATIVE BEST PRACTICES

33 CHIP guidelines Covered Dental Services are subject to a $564 annual benefit limit unless an exception applies. CHIP members who have exhausted the annual benefit limit continue to receive the following Covered Dental Services in excess of $564 annual benefit maximum: (1) The preventive services due under the 2009 American Academy of Pediatric Dentistry Periodicity schedule (Volume 32, Issue Number 6 at pp ) (2) Other Medically Necessary Covered Dental Services approved by the Dental Contractor through a prior authorization process. These services must be necessary to allow a CHIP Member to return to normal, pain and infection-free oral functioning. Documentation to support medical necessity must be submitted with the prior authorization. This includes narrative, x-rays and/or photos when x-rays are not possible. 33

34 CHIP Medically Necessary Services Typically includes services Related to the relief of significant pain or to eliminate acute infection. Related to treat traumatic clinical conditions. That allow member to attain the basic human functions (e.g. eating, speech, etc.). That prevent a condition from seriously jeopardizing member s health/functioning or deteriorating in an imminent timeframe to a more serious and costly dental problem. 34

35 Narratives A clear and comprehensive narrative is essential to ensure our dental directors understand the member s oral health. Effective narrative Tooth specific and describes member s symptoms Notes if member is on antibiotics Notes if member has been on pain killers for extended period of time Notes if age may be determining factor Any symptom present that is not identifiable on X-rays (inflammation or pain beyond normal eruption) Ineffective narrative Doesn t describe a condition that meets clinical criteria for approval. Example below doesn t demonstrate teeth are symptomatic. Impacted 1,16,17,32. Request removal due to pain A template or blanket statement that is used for every member. Recommending extraction for solely preventive reasons. 35

36 X-Rays Need to be mounted Claims with more than four un-mounted x-rays will be returned for mounting Should be of diagnostic quality, properly mounted, dated, marked with left and right, and identified with the member's name. Submission options in order of preference: Electronically using National Electronic Attachment or the provider web portal Mail duplicate x-rays with ADA form Send original x-rays, ADA form, and a self-addressed stamped envelope (SASE) Note: We are unable to return X-rays received without a SASE. X-rays without a SASE will be scanned and recycled 36

37 Emergency Pre-Authorizations Providers should be submitting emergency services as outlined in the ORM. The provider did not include any narrative with this request of why this would be considered an ER case, box 35. If this is a true ER, please have provider resubmit and include a definitive narrative as to why this should be an emergency. UM is unable to process these types of requests through . Please refer to for future reference regarding ER cases. I am including some definitions contained within our Policy 37 and Procedure for Expedited Authorizations for your

38 Appeals You have 120 days from the date of the EOB to submit an appeal. To submit an appeal, make a copy of the EOB and circle the claims in question. Please note why you are requesting the appeal and provide documentation such as a narrative, photos and X-rays to support medical necessity. If you don t have the EOB, you can submit the appeal using your office s letterhead. Please include the following information: Claim number Member name, date of birth and member ID Dentist name, NPI and TPI Explanation for the appeal Documentation such as a narrative, photos and X-rays to support medical necessity 38

39 submitting Appeals Mail DentaQuest-TX HHSC Dental Services Complaints & Grievances Stratum Executive Center Research Blvd Building D, Suite D-400 Austin, TX If the appeal is denied, you may request a peer-to-peer discussion by contacting the call center at

40 submitting Appeals Web portal Following these steps: Log onto the portal and click on Tools Then, click on Contact DentaQuest 40

41 submitting Appeals Web portal You will be redirected to a Message screen where you can submit information electronically (screenshot on next slide) You can only submit one attachment online so please ensure you enter the following in the Description box: Claim number Member name, date of birth and member ID Dentist name, NPI and TPI Explanation for the appeal NEA number for x-rays (if available) If x-rays aren t available via NEA, they can be uploaded as an attachment. If you have multiple attachments, you must zip the file prior to uploading it. 41

42 Reminder: It is not necessary to submit a copy of the ADA claim form and the EOB if all information regarding the claim is documented in the Description box and no changes are being made to the original ADA claim form. 42

43 Peer-to-Peer Requests All authorizations and claims are reviewed by experienced, Texas licensed dentists. This process gives you an opportunity to review clinical criteria and questions with a dental director. Request a call from one of our dentists by calling during business hours. The determination will not be changed during the peer-to-peer and the call does not guarantee approval or payment. 43

44 Like Specialty Peer-to-Peer If you have received a denied claim appeal, you may request a like specialty peer review. The specialist will be a non-contracted provider and their final determination is binding. Please refer to the ORM for more information on this process. 44

45 Quick access to provider resources: Enrollment Training Schedules Important Documents DentaQuest s Monthly Newsletter Contact DentaQuest Regional Provider Relations Representative DentaQuest 45

46 WEB PORTAL OVERVIEW

47 47 Enter your username and password to access the Dentist Home Page

48 Claims/Pre-Authorization Menu The Claims/Pre Authorization menu includes the following menu items: Claim/Pre-Authorization Status Search: Use this sub-menu item to search for the status of a claim or pre-authorization. Remittance Advice Search: Use this sub-menu item to view remittance advice statements. Dental Claim Entry: Use this sub-menu to enter and submit dental claims. Dental Pre-Authorization Entry: Use this sub-menu to enter and submit dental preauthorizations. Dental Claim Confirmation Report: Use this sub-menu to create a dental claims confirmation report. This report will list all claims that have been submitted through the web for that day. 48

49 Dental Claim Entry Key 1. Basic Information-Service Date, Group NPI, Service Office, Treating Dentist and POS (Place of Service). 2. Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency, COB,EPSDT, Notes. 3. Member Eligibility-DOB, Member ID, Last Name, First Name. 4. Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt. 5. File Attachments- click Add File to upload an attachment. 49 5

50 Dental Pre-Auth Entry Key Basic Information-Group NPI, Service Office, Treating Dentist and POS (Place of Service). 2. Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency, EPSDT, Notes. 3. Member Eligibility-DOB, Member ID, Last Name, First Name. 4. Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt. 5. File Attachments- click Add File to upload an attachment.

51 Claim/Pre-Authorization Status Search This page allows you to conduct a claim or pre-authorization search. **At least one search criteria must be entered to perform a search** Search Criteria Key: 1. Member Last Name 2. Member First Name 3. Member Number 4. Member DOB 5. Servicing Dentist 6.Claim/Pre-authorization Number 7. Type: Dental Claim or Pre- Authorization 8. Status Category: Successfully Entered, Accepted, In Process, Adjudicated, Finalized 9. Date From/To: Enter the Date of Service 10. Claim Received Date From/To: Enter the Claim or Pre-auth Received Date. 51

52 Claim/Pre-Authorization Status List This page appears with any claims or pre-authorizations that met your criteria search To download the list, click Download File. To view details on a claim/pre-authorization, click the Claim/Pre-Authorization Number link. To view the member s details for a claim, click the Member Name link. To view the Dentist Directory Detail page, click the Dentist link for a claim. To perform a new search, click Search Again. To perform a remittance advice search, click RA Search. 52

53 Questions?