General Information. Dental benefits only! Goes live 10/01/2012! Membership: 172,000 members Benefits are for under and over 21

Transcription

1 KY Medicaid

2 General Information Dental benefits only! Goes live 10/01/2012! Membership: 172,000 members Benefits are for under and over 21

3 Benefits Under 21 Some members pay a $2 copay per office visit (Group ID will show C at the end) The following members will not pay a copay: Members 18 and younger than the age of 18 years. Pregnant members. Members receiving services within the first 60 days after delivery of a baby. Members in a nursing facility. Members in a personal care home. Members in an intermediate care facility for people with mental retardation A foster child in state custody. An American Indian or Alaskan native served through KCHIP. Members in hospice care. Pacific Islanders

4 Benefits Under 21 cont 2 exams per year Limited to 14 PA x-rays Limited to 4 Bitewing x-rays 1 Panoramic per 24 month period; member under 5 requires prior-auth! If member has FMX (full mouth x-ray) done, x-rays w/ not be covered for the benefit period

5 Benefits Under 21 cont 2 cleanings per year 2 topical applications of fluoride per year 1 sealant per 48 months with a maximum of 3 times per tooth. 2 Space Maintainers per 12 months 1 filling per 12 months on the same tooth and surface

6 Benefits Under 21 cont 1 Root canal per tooth per lifetime Complete root canal therapy includes pulpectomy, all appointments necessary to complete treatment, temporary fillings, filling & obturation of canals, intra-operative and fill radiographs. In cases where a root canal filling does not meet Avesis' general criteria treatment standards, Avesis can require the procedure to be redone at no additional cost. Any reimbursement already made for an inadequate service may be recouped after review by the Avesis State Dental Director. Reimbursement includes local anesthesia.

7 Benefits Under 21 cont One deep cleaning per 12 months *Please note: D4341 will not require priorauthorization on this service until we are notified otherwise.

8 Benefits Under 21 cont No denture benefit! Check codes for other prosthodontics benefits!

9 Benefits Under 21 cont Extractions benefit available Check code for limitations!

10 Benefits Under 21 cont BRACES Lifetime max is $3,128 per case D8080: 2/3 of the life time benefit will be paid on the banding date 6 months later, we pay one more payment of $ to the provider and member is at lifetime max and we are done paying for ortho for that member. Adjunctive Services (Anesthesia) available!

11 Benefits Under 21: Pregnant Women Pregnant Women and Presumptive Eligibility Benefit (not on Medicaid, but pregnant may be offered Medicaid benefit for 90 days while they apply for Medicaid benefit.) They may receive up to three exams. (They receive an additional exam and additional plaque benefit)

12 Benefits Over 21 Some members pay a $2 copay per office visit (Group ID will show C at the end). The following members will not pay a copay: Pregnant members. Members receiving services within the first 60 days after delivery of a baby. Members in a nursing facility. Members in a personal care home. Members in an intermediate care facility for people with mental retardation A foster child in state custody. An American Indian or Alaskan native served through KCHIP. Members in hospice care. Pacific Islanders

13 Benefits Over 21 cont 2 exams per year Limited to 14 PA x-rays Limited to 4 Bitewing x-rays 1 Panoramic per 24 month period If member has FMX (full mouth) x-ray done, x-rays w/ not be covered for the benefit period

14 Benefits Over 21 cont 1 cleaning per year 1 filling per 12 months on the same tooth and surface No root canal benefit; check BRAIN for other Endo benefits!

15 Benefits Over 21 cont One deep cleaning per 12 months *Please note: D4341 will not require priorauthorization on this service until we are notified otherwise.

16 Benefits Over 21 cont Prosthodontic benefit: check for codes needing prior-auth! Extractions benefit available Check code for limitations! Adjunctive Services (Anesthesia) available!

17 Benefits Over 21: Pregnant Women Pregnant Women and Presumptive Eligibility Benefit (not on Medicaid, but pregnant may be offered Medicaid benefit for 90 days while they apply for Medicaid benefit.) They may receive two exams.

18 CoC Honoring all open authorizations from current vendor (MCNA) for 180 days. We are receiving open authorization list on 9/28, will be saved in clinical history.

19 CoC Orthodontics Passport s timeframe for orthodontic cases are good until the treatment is complete. Meaning if braces are approved, the authorization wouldn t expire until the treatment plan was complete.

20 Passport ID vs. Medicaid ID *Please note: Providers will not have the member s Medicaid ID # when calling to verify eligibility; therefore, please ask for member s name and DOB or Passport member ID to verify member under the OtherParentID field in AcH.

21 Provider Services Avesis is responsible for provider services, not member services. If a member call is received, please warm transfer member to Passport so that they may assist the member.

22 CAGs Avesis IS NOT responsible for 1 st call resolution for Passport members. Member calls should be transferred to Passport Health Plan Member Relations and they will document the complaint or grievance. Phone number: Member appeals will be routed to Avesis; Passport CS will advise member to send appeal in writing to Avesis. If member checking status of appeal, Passport CS will transfer call to Avesis to handle and resolve. Avesis is handling appeals 100% and sending out letters.

23 EPSDT Early Periodic Screening, Diagnosis & Treatment (EPSDT) Federally mandated for all Medicaid programs for children under the age of 21 In KY these services include what would normally be considered as non-covered or exceeding other plan benefit limitations

24 ESPDT Cont If a member is in need of service that is not a normal covered service, the provider is required to obtain Prior Authorization for these services by sending in a PTE.

25 ESPDT Cont All providers will be automatically EPSDT providers until the remainder of the year. A separate Medicaid ID is not required. KCHIP 3 members do not receive expanded EPSDT benefits

26 Eligibility Inquiries Members not showing up in HEAT Ask for member s name, DOB or Passport ID # to perform proper member search. If Avesis receives an eligibility inquiry from a member who is stating he/she is a Passport member but the member does not appear on the eligibility file that Avesis received, refer the member to Member Services If Avesis receives an eligibility inquiry from a provider who has a member in the office and is stating he/she is a Passport member but the member does not appear on the eligibility file, Avesis may contact Passport Provider Services at

27 Medical or Anesthesia Services Providers inquiring about medical or anesthesia services should contact Passport CS at

28 Additional Information 180 days for timely filing on Claims All providers are contracted Passport Providers. Providers don t have to credential with Avesis. If provider states they are in-net with Passport but they are not in system, refer to Angel, Felicia and/or Yolanda.

29 COB We will be receiving COB benefit information. We should only verify other DENTAL coverage

30 Contacts New PSR: Felicia Wheeler Account Manager: Yolanda Gaddy Credentialing Specialist Lead: Angel Sierra

31 Prior-Authorization Turn around time for PTE is 2 business days.

32 Card