Idaho MMIS Provider Handbook

Transcription

1 Table of Contents 1. Section Modifications Guidelines General Policy Participant Eligibility Medicaid Basic Plan and Pregnant Women (PW) Program Medicaid Enhanced Plan Qualified Medicare Beneficiary (QMB) Program Medicare-Medicaid Coordinated Plan (MMCP) Healthy Connections (HC) Program Reimbursement Covered Benefits and Limitations Overview Descriptive Codes Children s Services Preventive Procedures D D Restorative Procedures D D Endodontics D D Periodontics D D Prosthodontics D D Maxillo-Facial Prosthetics D5931 D Oral Surgery D D Orthodontics D D Adjunctive General Services D D Pregnant Women (PW) Services Adult Services Denturist Policy Guidelines Overview Reimbursement Service Limitations Participant Eligibility Qualified Medicare Beneficiary (QMB) Medicare-Medicaid Coordinated Plan (MMCP) Prior Authorization (PA) How to Request Prior Authorization Claim Form Billing Which Claim Form to Use August 2010 Page i

2 1. Section Modifications Section/ Column Modification Description Date SME All Replaced member with participant 8/17/2010 C Stickney 2.7 Updated PA information 8/17/2010 C Stickney All Updated numbering for sections to accommodate Section Modifications 8/17/2010 C Stickney August 2010 Page 1 of 11

3 2. Guidelines 2.1. General Policy This section covers Medicaid services provided by dentists and denturists as deemed appropriate by the Department of Health and Welfare (DHW). It addresses the following. guidelines Denturist guidelines Claims billing Claims payment Prior authorization See General Billing Information for information on electronic billing Participant Eligibility Medicaid Basic Plan and Pregnant Women (PW) Program This handbook applies to children and adults who are eligible for Medicaid s Enhanced medical and dental program. Participants participating in Basic dental will receive an Idaho Smiles card. Children and adults who are eligible under the Medicaid Basic Plan, including pregnant women eligible for the Pregnant Women (PW) Program, are covered under a dental insurance program called Idaho Smiles. Contact Idaho Smiles Customer Service at 1 (800) , or by at and click on the Idaho Smiles link for Idaho Smiles eligibility benefits, and claims processing information. Note Participants identification numbers for both Idaho Smiles and Medicaid are the same. If a participant does not have an Idaho Smiles insurance card, you can still use their Medicaid identification (MID) number on the Health PAS-OnLine website, or Medicaid Automated Customer Service (MACS) at 1 (866) toll free, to determine eligibility. The eligibility response from Idaho Medicaid will indicate which dental program the participant is on. If the response indicates the participant is eligible for the Medicaid Basic Plan or the Pregnant Women (PW) Program, bill Idaho Smiles for dental services. If the response indicates the participant is eligible for Medicaid, without mention of the Medicaid Basic Plan or the PW Program, bill Idaho Medicaid for dental services Medicaid Enhanced Plan Medicaid participants who are on Medicaid s Enhanced Plan are eligible for dental benefits as outlined in Section 2.3 Covered Benefits and Limitations. Bill Idaho Medicaid for dental services for Medicaid Enhanced Plan participants Qualified Medicare Beneficiary (QMB) Program Participants eligible under only the QMB Program, with no other active Medicaid eligibility, are not eligible for dental benefits. August 2010 Page 2 of 11

4 Medicare-Medicaid Coordinated Plan (MMCP) Participants on the MMCP have denture benefits through their insurance carrier; contact the participant s insurance carrier for more information Healthy Connections (HC) Program Healthy Connections is Idaho Medicaid s primary care case management (PCCM) model of managed care. services do not require a HC referral Reimbursement Medicaid reimburses dentists on a fee-for-service basis at usual and customary fees, up to the Medicaid maximum allowance. If the provider accepts any Medicaid payment for a covered service, the Medicaid payment must be accepted as payment in full and the participant cannot be billed for the difference between the billed amount and the Medicaid allowed amount. Dentists may make arrangements for private payment with families for services that are not covered by Medicaid if the patient or financially responsible party is informed that the services are not covered by Medicaid before they are rendered. (Arrangements should preferably be in writing.) To obtain a copy of the Idaho Medicaid dental reimbursement schedule, write to Division of Medicaid Attn: Unit PO Box Boise, ID Non-Covered Services Non-covered services are procedures not recognized by the American Association (ADA) or services not listed in this handbook Covered Benefits and Limitations Overview This portion of the handbook lists the dental services that are covered for participants on the Medicaid Enhanced Plan, with specific limitations and exclusions. See the most recent Current Terminology (CDT) reference manual published by the American Association (ADA) for full definitions. Children s Services are services provided to children ages 0-21 (through the month of their 21 st birthday). Adult Services are services provided to adults who have completed the month of their 21 st birthday. August 2010 Page 3 of 11

5 Descriptive Codes Designation of Teeth Permanent teeth A - T Deciduous (primary teeth) Areas of the Oral Cavity 00 Whole of the oral cavity 01 Maxillary area 02 Mandibular area 10 Upper right quadrant 20 Upper left quadrant 30 Lower left quadrant 40 Lower right quadrant For examples, refer to the most current version of the Current Terminology (CDT) reference manual. Supernumerary Teeth Services on supernumerary teeth require prior authorization from the Medicaid Unit Children s Services Examinations are not allowed in any combination on the same day. See ADA Instructions for covered dental services Preventive Procedures D D1999 Medicaid provides no additional allowance for a cavitron or ultrasonic prophylaxis Restorative Procedures D D2999 All restorations must be documented in the participant s record to include procedure, surface(s), and tooth number (if applicable). This record must be maintained for a period of five years. When a multi-surface restoration is billed, the surfaces listed on the claim form must equal the number of surfaces billed. Failure to identify all the surfaces billed will result in denial of service Posterior Restoration A one surface posterior restoration is one in which the restoration involves only one of the five surface classifications, mesial, distal, occlusal, lingual, or facial, including buccal or labial. A two surface posterior restoration is one in which the restoration extends to two of the five surface classifications. A three surface posterior restoration is one in which the restoration extends to three of the five surface classifications. August 2010 Page 4 of 11

6 A four or more surface posterior restoration is one in which the restoration extends to four or more of the five surface classifications Anterior Proximal Restoration A one surface anterior proximal restoration is one in which neither the lingual nor facial margins of the restoration extends beyond the line angle. A two surface anterior proximal restoration is one in which either the lingual or facial margins of the restoration extends beyond the line angle. A three surface anterior proximal restoration is one in which both the lingual and facial margins of the restorations extend beyond the line angle. A four or more surface anterior restoration is one in which both the lingual and facial margins extend beyond the line angle and the incisal angle is involved Amalgams and Resin Restorations Reimbursement for pit restoration is allowed as a one surface restoration. Adhesives (bonding agents), liners, bases, and the adjustment and/or polishing of sealant and restorations are included in the allowance for the major restoration. Liners and bases are included as part of the restoration. If pins are used, they should be reported separately Crowns Prior authorization is required for codes D2710 D2792.When submitting for prior authorization you must include one of the following. An x-ray showing the root canal An x-ray with a written justification detailing the amount of tooth structure missing An x-ray with a written explanation of definitive symptoms of a vertical fracture Note Requests for re-doing crowns must be submitted for prior authorization and include x-ray and justification Local Anesthesia Local anesthesia is considered to be part of restorative procedures and therefore is not a separately billable service Endodontics D D3999 Pulpotomies and root canal procedures cannot be paid with the same date of service for the same tooth. Local anesthesia is considered to be part of endodontic procedures. See ADA Instructions for covered dental services Periodontics D D4999 Services (including usual postoperative care) Local anesthesia is considered to be part of periodontal procedures. August 2010 Page 5 of 11

7 Prosthodontics D D Removable Prosthodontics D D5899 Complete dentures placed immediately must be of structure and quality to be considered the final prosthesis. Transitional or interim treatment dentures are not covered. No additional reimbursements are allowed for denture insertions. Routine post-delivery care, including complete and partial denture adjustments and relines, are considered part of the initial denture construction service for six months after delivery of the dentures. A separate exam fee will not be allowed during that time for problems related to the dentures. Note Claims for full, immediate, or partial dentures should not be billed to Medicaid until they are delivered to the participant. The impression date may only be used for billing when partial or complete dentures are delivered during a month when the participant is not eligible, but other work, including laboratory work, is completed during an eligible period Limitations on Dentures The Medicaid Program covers only one partial or complete denture per arch, every five calendar years. A participant who receives a partial denture, and then needs a full denture, is allowed both within a 5 year period. Replacement of lost or broken dentures within the five year period is not covered. Partial dentures for children under the age of 12 require prior authorization. When billing for flippers, use the appropriate ADA interim partial denture code. Do not bill a partial denture code for flippers. Interim partial dentures require prior authorization for children up to age 21. Note: Flippers or interim partial dentures are not covered for adults Undelivered Dentures Laboratory and professional fees may be paid under procedure code D5899, with prior authorization, for an undelivered partial or complete denture if the participant meets one of the following conditions. The participant decided not to complete the partial or complete denture. The participant returned the denture(s) within 90 days of delivery because they were dissatisfied with the denture(s). The participant left the state. The participant cannot be located. The participant is deceased. If the participant returns denture(s) within 90 days of delivery, refund 100 percent of Medicaid s payment to Medicaid and contact the Medical Care Unit at 1 (208) for further instructions. Dentists and denturists who have already received payment for dentures but were unable to deliver the dentures, for any of the reasons stated above, must refund the entire Medicaid payment, and then request prior authorization for D5899. Failure to follow this process with undelivered dentures is considered accepting payment for services not rendered. August 2010 Page 6 of 11

8 Dentures Provided by a Dentist Medicaid s payment for dentures includes routine adjustments up to six months from the date dentures were placed in the mouth. Participants are expected to notify the provider of any problems they are having with the denture(s) and return to the provider for needed adjustments within the six month period Dentures Delivered and Returned by Participant If a participant returns unsatisfactory dentures within the six month adjustment period, the provider should notify the Medical Care Unit at 1 (208) Participants who do not return unsatisfactory dentures to the dentist within six months of placement are not eligible for another denture or set of dentures for five years Dentures Provided by a Denturist When a denturist provides dentures, the 90 day unconditional Guarantee of Denturist Services, as outlined in IDAPA Guarantee of Denturist Services, and Idaho Statute Title 54, Chapter 3320 Guarantee on Services, applies. If the participant returns denture(s) within 90 days of delivery, refund 100 percent of Medicaid s payment to Medicaid and contact the Medical Care Unit at 1 (208) for further instructions. Participants who return unsatisfactory dentures to a denturist after the 90 day guarantee on services period are not eligible for additional dentures for five years. Note Local anesthesia is considered to be part of removable prosthodontic procedures Maxillo-Facial Prosthetics D5931 D5999 Maxillo-Facial Prosthetics: Prior authorization is required for codes D D Fixed Prosthodontics D D6999 Other Fixed Partial Denture Services Procedure codes D6210 through D6920 are not a Medicaid covered benefit. Local anesthesia is considered to be part of fixed prosthodontic procedures Oral Surgery D D7999 Extraction codes include services for local anesthesia, suturing, and routine preoperative and postoperative care. Note For oral and maxillofacial surgeons, most surgical procedures in the D D7996 category can be converted to the CPT coding system and can be submitted electronically or using a CMS-1500 claim form. Use your medical provider number on these claims Orthodontics D D8999 Orthodontics Prior authorization requests need to be submitted to Department of Health and Welfare (DHW) prior to providing orthodontia. Orthodontics are limited to participants age 0-21 years who meet the eligibility requirements, and the Handicapping Malocclusion Index as evaluated by the Idaho Medicaid dental consultants. August 2010 Page 7 of 11

9 Transfers Participants already in orthodontic treatment who transfer to Idaho Medicaid must have their continuing treatment justified and authorized by the Idaho Medicaid dental consultants. Limited Orthodontics Limited Orthodontics is treatment with a limited objective, not involving the entire dentition. It may be directed at the only existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy. Comprehensive Orthodontic Treatment The coordinated diagnosis and treatment leading to the improvement of a participant s craniofacial dysfunction and/or dentofacial deformity including anatomical, functional, and aesthetic relationships. Treatment usually, but not necessarily, utilizes fixed orthodontic appliances, and can also include removable appliances, headgear, and maxillary expansion procedures. It must score at least eight points on the state s Handicapping Malocclusion Index Adjunctive General Services D D9999 See the ADA Instructions Pregnant Women (PW) Services Women who are eligible under the PW program are covered by a dental insurance program called Idaho Smiles. Contact Idaho Smiles Customer Service at 1 (800) , or by at and click on the Idaho Smiles link, for Idaho Smiles eligibility, benefits, and claims processing information Adult Services A Medicaid participant is considered to be an adult as of the first day, of the first month, after their 21 st birthday. Services for Medicaid adult participants are currently limited to the tables in the ADA Instructions. Codes in the tables may have abbreviated descriptions Denturist Policy Guidelines Overview Approved services are limited to those services allowed by Idaho code for Idaho licensed denturists. Claims may be submitted electronically or on an approved American Association (ADA) claim form Undelivered Dentures by a Denturist Laboratory and professional fees may be paid under procedure code D5899, with prior authorization, for an undelivered partial or complete denture if the participant meets one of the following conditions. The participant has decided not to complete the partial or complete denture. The participant returned the denture(s) within 90 days of delivery because they were dissatisfied with the denture(s). The participant has left the state. The participant cannot be located. August 2010 Page 8 of 11

10 The participant is deceased. If the participant returns denture(s) within 90 days of delivery, refund 100 percent of Medicaid s payment to Medicaid and contact the Medical Care Unit at 1 (208) for further instructions. Failure to follow this process with undelivered dentures is considered accepting payment for services not rendered Reimbursement Denturists will be reimbursed 85% of the Dentist fee schedule. If a provider accepts Medicaid payment for a covered service, the Medicaid payment must be accepted as full payment and the participant cannot be billed for the difference between the billed amount and the Medicaid allowed amount Service Limitations Complete and partial denture adjustments and relines are considered part of the initial denture construction service for the first six months. After six months, denture reline is allowed once every two years. Only one upper and one lower partial or full denture is covered in a five calendar year period. Complete dentures, placed immediately, must be of structure and quality to be considered the final prosthesis. Transitional or interim treatment dentures are not covered. No additional reimbursement is allowed for denture insertions. If complete dentures are inserted during a month when the participant is not eligible, but other work, including laboratory work, is completed during an eligible period, the claim for the dentures is allowed. Use the impression date, not the seating date, as the service date Participant Eligibility Eligibility must be verified with Health PAS-OnLine at or Medicaid Automated Customer Service (MACS) before services are rendered. Contact MACS at 1 (208) (866) Provider representatives are available Monday through Saturday from 7 a.m. - 7 p.m. MT (including state holidays) Qualified Medicare Beneficiary (QMB) Participants who have only QMB are not eligible for dentures Medicare-Medicaid Coordinated Plan (MMCP) For participants who have denture benefits through their insurance carrier, contact the participant s insurance carrier for more information. August 2010 Page 9 of 11

11 2.7. Prior Authorization (PA) How to Request Prior Authorization All procedures that require prior authorization must be approved prior to the service being rendered. Prior authorization requires submission of the appropriate dental prior authorization form and diagnostics. Verbal authorizations will not be given. Retroactive authorization will be given only in an emergency situation or as the result of retroactive eligibility. Note Any questions regarding the prior authorization procedure or prior authorization requirements should be addressed to the Medical Care Unit at 1 (208) Prior authorization of Medicaid dental procedures does not guarantee payment. The participant s Medicaid eligibility must be verified by the provider before the authorized service is rendered. Prior authorization forms for general dentistry and orthodontics are located at Health PAS- OnLine or a paper copy can be requested from provider services. They can be duplicated as needed. The forms must be filled out completely. Attach or include any pertinent information to substantiate the request for PA, such as x- rays, models, and narratives when appropriate. A Medicaid dental consultant reviews the requested procedure(s) with documentation and returns the approvals or denials via a Notice of Decision for Medical Assistance Benefits letter. If the request for prior authorization is denied, a dental consultant's explanation will be included. Claims for services requiring PA will be denied if the provider did not obtain a PA from the authorizing authority. Participants must be Medicaid eligible on the date of service or the prior authorization is void. See General Billing Information, Medicaid Prior Authorizations, for more information on electronically billing services that require prior authorization. Send prior authorization requests to Division of Medicaid Attn: Unit PO Box Boise, ID Fax: 1 (877) Submit In Writing for Prior Authorization (PA) Changes If changes are required on a prior authorization, such as a procedure that was done outside of the Start and Stop dates, or another procedure was provided rather than the procedure that was initially authorized, submit in writing to the address above requesting the change. Include the participant s name, Medicaid identification number, prior authorization number, tooth number(s) or quadrant designations, if applicable, and what needs to be changed. August 2010 Page 10 of 11

12 2.8. Claim Form Billing Which Claim Form to Use Claims received more than one year after the date of service (365 days) are not covered. Idaho Medicaid only accepts the ADA 2006 claim form. See General Billing Information, for more details on claims billing and timely filing General Billing Instructions Prior Authorization Number Claims for services requiring PA will be denied if the provider did not obtain a PA from the authorizing authority. National Oral Cavity Designation (Quadrant) Codes Idaho Medicaid accepts the National Oral Cavity Designation Codes (quadrant codes) on electronic and paper dental claims. Idaho Medicaid does not accept the sextant codes. Multiple Tooth Designations per Detail Although HIPAA allows multiple tooth designations per detail, Idaho Medicaid can only accept one tooth designation and unit per detail. Oral Surgeons When billing for extractions, use the correct CDT procedure code and the ADA 2006 claim form or electronic HIPAA 837 Transaction. Use your Medicaid dental provider number. Place-of-Service (POS) Codes The following POS codes are allowed for dental providers. Not all of the POS (except for 11 Office) listed are available for every procedure. Please verify with MACS or Idaho Medicaid Provider Services prior to rendering services outside of the provider office. POS Codes 11 Office 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room 24 Ambulatory Surgical Center 31 Skilled Nursing Center 32 Nursing Facility 54 Intermediate Care Facility (for Developmentally Disabled)/Mentally Retarded (ICF/MR) 71 Public Health Clinic Modifiers Although HIPAA allows up to four modifiers, Idaho Medicaid does not accept modifiers for dental services. August 2010 Page 11 of 11