Dental Policy and Prior Authorization. Spring 2018

Transcription

1 Dental Policy and Prior Authorization Spring 2018

2 CLASS DESCRIPTION A look at current OHCA dental policy, coverage for new procedures, and how to submit a dental prior authorization (PA) on the SoonerCare Provider Portal.

3 CREATE PRIOR AUTHORIZATION (PA)

4 CREATE PA, CONT.

5 DIAGNOSIS INFORMATION IS REQUIRED

6 DIAGNOSIS INFORMATION RESOURCES See Dental ICD-10 Information (under Commonly Used Forms) ICD-10 Google search

7 DO NOT add service until all attachments have been added CREATE PA, CONT.

8 ADD ELECTRONIC ATTACHMENTS

9 ADD BY MAIL ATTACHMENTS

10 ATTACHMENTS ARE LISTED

11 Add service after all attachments are complete ADD SERVICE

12 SUBMIT Continue to add services (maximum of 12 line items are allowed per authorization request), then submit when finished

13 CONFIRM

14 AUTHORIZATION RECEIPT BY MAIL attachments require the HCA-13D coversheet

15 DENTAL AUTHORIZATION ATTACHMENT COVERSHEET HCA-13D A B

16 VIEW AUTHORIZATION STATUS

17 ENTER SEARCH CRITERIA DO NOT USE B

18 SEARCH RESULTS Click on prior authorization number to open

19 VIEW AUTHORIZATION RESPONSE Click on Print Preview or blue hyperlinks to obtain tooth numbers and remarks

20 VIEW AUTHORIZATION RESPONSE, CONT.

21 ADVANCED SEARCH B Advanced search allows you to see all of a members dental prior authorizations regardless of requesting provider Mickey Mouse

22 ATTACH PENDING DOCUMENTS

23 ATTACH PENDING DOCUMENTS, CONT. B Click on + sign to open an attachment box

24 ATTACH PENDING DOCUMENTS, CONT. B Transmission Method box opens up to allow you to attach requested documents Original attachments are shown

25 ATTACH PENDING DOCUMENTS, CONT. B After all pending documents are added then click on submit

26 ATTACH PENDING DOCUMENTS, CONT. Once you receive this message DO NOT hit submit again or you will get an error. bb99b B

27 SEARCH NOTICES

28 SEARCH NOTICES, CONT.

29 TREATMENT HISTORY

30 TREATMENT HISTORY, CONT.

31 TREATMENT HISTORY RESULTS B Click on blue hyperlinks to view more information

32 TREATMENT HISTORY, CONT. B

33 REQUIRED DOCUMENTS FOR PAs Minimum records to be submitted with every dental request include: HCA-13D coversheet for BY MAIL dental PAs Periapical films of tooth/teeth involved Right and left bitewing X-rays Comprehensive treatment plan Six-point periodontal charting, if requesting periodontal services

34 REQUIRED DOCUMENTS FOR ORTHODONTIC PAs Minimum records to be submitted with comprehensive orthodontic request: Completed and scored handicapping labio-lingual deviations index (DEN-6) with diagnosis of angle s classification Intraoral photographs showing teeth in centric occlusion and/or photographs of trimmed anatomically occluded diagnostic casts A lingual view of casts may be included to verify impinging overbites

35 REQUIRED DOCUMENTS FOR ORTHODONTIC PAs, CONT. Detailed description of any oral maxillofacial anomaly Estimated length of treatment Cephalometric X-rays with tracing, and panoramic film If diagnosed as a surgical case, submit an oral surgeon s written opinion that orthognathic surgery is indicated and the surgeon is willing to provide the service Referral from general dentist (DEN-2) Caries risk assessment

36 COMMON LINE ITEM ERRORS Each requested service must have its own line item For example: D4341 D4341 D4341 D4341 UR UL LR LL Incorrect: D units

37 SILVER DIAMINE FLUORIDE OHCA has opened dental code D1354 for use of silver diamine fluoride (SDF), for "interim caries arresting medication application. SDF is a major topic of discussion in dentistry lately - described as a caries silver-fluoride bullet - and some have ventured to say it could eliminate the use of the drill altogether in treating children s cavities SDF is noninvasive, quick and inexpensive, which makes it an attractive option for treating SoonerCare children

38 SILVER DIAMINE FLUORIDE, CONT. Dental code D1354 can be used to bill for services provided to SoonerCare members To limit any abuse, the following administrative rules are in place (subject to change): For a child who is documented to be unable to receive restorative services in the typical office environment A tooth that has been treated with SDF should not have any non-carious structure removed A tooth that has been treated with SDF should not receive any other permanent restorative treatment for three months following an application

39 SILVER DIAMINE FLUORIDE Administrative rules, cont. Reimbursement or extraction of a tooth that has been treated with SDF will not be allowed for three months following an application Reimbursement is available once every 184 days for two occurrences per tooth in a lifetime Reimbursement will be equal to that of a sealant, currently $22.56, limited to eight teeth per series For more information on SDF and its usage, you may want to read UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications and Consent (Horst JA, Ellenikiotis H, Milgrom PL. J Calif Dent Assoc. January 2016)

40 (1) Adults. ADULT DENTAL SERVICES (A) Dental coverage for adults is limited to: (i) emergency extractions, as defined in OAC 317: Tooth extraction must have medical need documented (ii) limited oral examinations and medically necessary images associated with the emergency extraction or with a clinical presentation with reasonable expectation that an emergency extraction will be needed

41 ADULT DENTAL SERVICES, CONT. (iii) Smoking and Tobacco Use Cessation Counseling; and (iv) medical and surgical services performed by a dentist or physician to the extent such services may be performed under State law when those services would be covered if performed by a physician

42 ADULT DENTAL SERVICES, CONT. Extraction code D7241 requires PA for ages 21 and older "Emergency Dental Care" includes, but is not limited to, the immediate service that must be provided to relieve the member from pain due to an acute infection, swelling, trismus or trauma

43 CONTACT US Dental Prior Authorization Provider Services

44 DENTAL PRIOR AUTHORIZATION TEAM Dr. Courtney Barrett Dentist Dr. Bernard Rhone Dentist Dr. Richard Gilman Orthodontic Consultant Tracy Matthews Dental Program Coordinator Dana Drew Dental Analyst Sara Gillum Dental Analyst Wendy Payne Dental Analyst Tiira Carreon Administrative Assistant

45 Questions