MassHealth Presentation. November 2017

Transcription

1 MassHealth Presentation November 2017

2 Agenda Introductions / Overview Benefit Changes, July 1, 2017 Orthodontic Billing Changes, November 1, 2017 Children s Medical Security Plan, July 1, 2017 Benefit Changes, January 1, 2018 Other Important Information MassHealth Outreach Programs Questions? 2

3 DentaQuest Team Tracy Chase Gilman, Regional Director Phone: Marianne Leahy, Vice President, Network Management Phone: Keishia Lopez-Christian: Provider Relations Representative (Boston and Southern MA) Phone: Daniel Archambault: Provider Relations Representative (Western MA) Phone: Flor Piedrasanta: MassHealth Outreach Coordinator 3

4 Feedback 4 4

5 Public Health Dental Hygienists, New Codes New Code: D0190 CDT Definition Description: Oral Screening (New Code) Screening of a patient: A screening, including state or federally mandated screenings, to determine an individual s need to be seen by a dentist for diagnosis. Limitation Fees Two (2) per calendar year per member, per provider. No prior authorization required. Adult- $20 Under 21- $29 New Code: D0191 CDT Definition Description: Limit Clinical Assessment (New Code) Assessment of a patient: A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment. Limitation Change Fees One (1) per calendar year per member, per provider. No prior authorization required. Adult- $20 Under 21- $29 5

6 Dental Regulation: Diagnostic Services Oral Screening. The MassHealth agency pays for an oral screening twice per calendar year per member per provider. An oral screening may only be billed by Public Health Dental Hygienists. An oral screening includes state or federally mandated screenings to determine a member s need to be seen by a dentist for further diagnosis. Limited Clinical Assessment. The MassHealth agency pays for a limited clinical inspection once per calendar year per member per provider. A limited clinical assessment may only be billed by Public Health Dental Hygienists. A limited clinical assessment includes identification of possible signs of oral or systemic disease, malformation, injury, and/or the potential need for a referral for diagnosis and treatment by a dentist. 6

7 Dental Regulation: Provider Eligibility : Provider Eligibility: Participating Providers (A) A dentist or public health dental hygienist who is a member of a group practice can direct payment to the group practice under the provisions of the MassHealth regulations governing billing intermediaries in 130 CMR : Administrative and Billing Regulations. The dentist or public health dental hygienist providing the services must be enrolled as an individual provider, and must be identified on claims for his or her services. (B) A dental school may claim payment for services provided in its dental clinic. (C) A dental clinic may claim payment for services provided in its dental clinic. (D) A community health center, hospital-licensed health center, or hospital outpatient department may claim payment for services provided in its dental clinic. 7

8 Dental Regulation: Provider Types : Provider Eligibility In-state and Out-of-state (2) Community Health Center. A licensed community health center with a dental clinic is eligible to participate in MassHealth as a provider of dental services. (5) Dental Clinic. A dental clinic must be licensed by the Massachusetts Department of Public Health (DPH) to be eligible to participate in MassHealth as a dental provider. A DPH license is not required for a state owned and operated dental clinic. A dental clinic that limits its services to education and diagnostic screening is not eligible to participate in MassHealth as a dental provider. (9) Public Health Dental Hygienist. A dental hygienist engaged in private practice is eligible to participate in MassHealth as a dental provider and claim payment for certain services without the direct supervision of a dentist if he or she is licensed to practice as a registered dental hygienist by BORID and also meets the Board s requirements to practice in a public health setting pursuant to 234 CMR 2.00: General Rules and Requirements et seq. Private practices may include, but are not limited to, solo, partnership, or group practices. 8

9 Silver Diamine Fluoride Code Definition Covered? D1354 Interim carries arresting medicament application, per tooth Conservative treatment of an active, non-symptomatic carious lesion by topical application of caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure. Non-covered 9

10 Denture Radiograph Requirement Removable Prosthodontics (Full and Partial Dentures) Some procedures require retrospective review documentation. Please refer to Exhibits A-D covered services tables for specific information needed by code. Documentation needed for procedure: If the member still has natural teeth, appropriate pre-operative radiographs showing clearly the adjacent and opposing teeth: bitewings, periapicals or panoramic radiograph are required. If the member has no remaining teeth, radiographs are not required. Appropriate pre-operative radiographs are required for patients who just became edentulous and all non-edentulous patients clearly showing the adjacent and opposing teeth or if edentulous, the edentulous jaw : bitewings, periapicals or a panoramic radiograph are required. Criteria for Removable Prosthodontics (Full and Partial Dentures) Prosthetic services are intended to restore oral form and function caused by premature loss of permanent teeth that would result in significant occlusal dysfunction. A denture is determined to be an initial placement if the patient has never before worn a prosthesis or had a prosthesis prescribed by any provider at any time. Dentists are required to take diagnostic quality pre-operative radiographs for complete denture services. 10

11 Periodontal Code Changes, Effective July 1, 2017 Codes: D4341, D4342 Description: D4341-Periodontal scaling and root planning - four (4) or more teeth per quadrant. D4342-Periodontal scaling and root planning one (1) to three (3) teeth per quadrant Limitation changed from thirty six (36) months to three (3) calendar years. (Beginning of the 3 rd calendar year) Limitation Change Not payable in conjunction with D1110 and D1120 or D4210 and D4211 on the same date of service. Office: One (1) of D4341 or D4342 per three (3) calendar years per patient, per quadrant. Two (2) of D4341 or D4342 per one (1) day per provider or location in office. Hospital: Four (4) of D4341, D4342 per one (1) day per provider or location in hospital. 11

12 Benefit / Language Changes 12

13 Benefit Changes, Effective July 1, 2017 New Code: D0180 Who is covered? Description: Comprehensive Periodontal Evaluation (New Code) MassHealth Under 21 MassHealth Adult MassHealth DDS HSN Only Under 21 HSN Only Adult One (1) per calendar year per provider or location. No prior authorization. Limitation Not covered with D9110 Palliative (emergency) treatment of dental pain minor procedure or D0140 limited oral evaluation problem focused, by same provider or provider group on same date of service. Periodontal charting to be maintained in patient s chart. Fees Adult: $37 Under 21: $58 13

14 Benefit Changes, Effective July 1, 2017 Code: D0330 Description: Panoramic Radiographs Limitation Change Payment will not be allowed for D0330 if it billed on the same date of service with codes related to orthodontic, crowns, endodontic codes, periodontic codes or restorations / interproximal caries. Codes: D2140-D2394 Limitation Change Description: Restorations (Fillings) (Calendar year + Reimbursement Cap) Limitation change from twelve (12) months to a calendar year. One (1) per calendar year per provider per location per tooth. MassHealth will not pay for restorations placed on two (2) or more surfaces within twelve (12) months on the same tooth as separate restorations. Claim submitted as separate restorations will be paid at the appropriate multi surface restoration rates. 14

15 Benefit Changes, Effective July 1, 2017 Updated November Coming Code: D0270, D0272, D0273, D0274 Limitation Change Description: Bitewing Radiographs Two of (D0270, D0272, D0273, D0274) per 1 Calendar year(s) Per Provider OR Location. One of (D0270, D0272, D0273, D0274) per 1 Day(s) Per patient. Only one of (D0270, D0272, D0273, D0274) can be billed on the same date of service. Any combination of radiographs that exceeds the maximum allowable payment for a FMX will be reimbursed at the D0210 rate. Documentation of variation from ADA clinical guidelines to be kept in patient record. Any combination of radiographs that exceeds the maximum allowable payment for a FMX will be reimbursed at the D0210 rate. Documentation of variation from ADA clinical guidelines to be kept in patient record. For Example: Deny the D0272 (double) and D0272 (double) from being billed together on the same date. Deny the D0270 (single) and D0273 (triple) from being billed together on the same date. 15

16 Orthodontic Benefit Changes, Effective November 1, 2017 Codes: D8670 Action Limitation Description: Periodic Orthodontic Treatment Visit Codes: D8670 Action Limitation Description: Periodic Orthodontic Treatment Visit Change billing cycle from monthly to quarterly (every 90 days) Each quarterly billing period starts on the date the member receives the first adjustment The first date that a quarterly payment for an adjustment can be paid is for a date of service in the month after the last date of service claim. For example, if an adjustment service was paid for the date of service of October 15, 2017 the earliest date a quarterly adjustment payment could be paid would be November 1, 2017 One of D8670 per 90 day(s) per patient. The first adjustment (D8670) may not be billed in the same calendar month as banding (D8070, D8080) Only payable to a dental provider with a specialty of Orthodontics Please review billing instructions in Section 16 of the Office Reference Manual Fee: Fee: $268/Child-EPSDT (under 21) $200/Adult (21 and over) 16

17 Children s Medical Security Plan (CMSP) DentaQuest became the TPA for the Children s Medical Security Plan Effective July 1, The Children's Medical Security Plan (CMSP) is a program that provides certain uninsured children and adolescents with primary and preventive medical and dental coverage. Populations Served: o CMSP is for children under the age of 19 who are Massachusetts residents at any income level, who do not qualify for MassHealth (except MassHealth Limited), and who are uninsured. Some examples of services not covered by CMSP under MassHealth include: o Cosmetic Services o Orthodontic Services Please note: o The service history for MassHealth and the Health Safety Net will be taken into consideration prior to payment for any covered service. 17

18 Children s Medical Security Plan (CMSP) MassHealth- State Fiscal Year Annual Maximum: CMSP-covered services include dental services, up to the $750 maximum per state fiscal year (SFY), including preventive dental care under the MassHealth plan. CMSP benefits are calculated on a state fiscal-year basis. The state fiscal year starts on July 1st and continues through June 30th. Members who have only CMSP coverage or choose to see a provider who is not a Health Safety Net (HSN) participating provider may have a patient responsibility after the processing of claims once the $750 state fiscal year maximum has been reached. If a member has CMSP and HSN coverage and they see a Health Safety Net participating provider, the balance remaining or any other covered services provided after reaching the SFY maximum will be paid under the Health Safety Net with no patient responsibility. 18

19 Children s Medical Security Plan (CMSP) SPECIAL NOTE: As of July 1, 2017 the CMSP remittance advice may not always correctly calculate the member financial responsibility for members who have reached the $750 annual allowable maximum per state fiscal year. The issue is actively being worked and MassHealth will communicate to the providers when the corrections to the logic to calculate member responsibility have been made. Until a fix has been implemented providers can determine the member responsibility in the following manner: o If the members reaches the $750 annual allowable maximum within a state fiscal year the service line will reference a processing policy Remaining Patient Liability Present (Detail). This information will alert the provider that there is member payment responsibility associated with the service. o If MassHealth has paid a partial amount before the member reaches their maximum the provider is held to the MassHealth allowable amount. In this instance the member responsibility is the difference between the amount paid by MassHealth and the MassHealth allowable amount (fee). o If nothing was paid by MassHealth the service is considered non-covered. The provider may charge the member the MassHealth allowable amount (fee). 19

20 This image cannot currently be displayed. Accumulator- CMSP MassHealth 20

21 CMSP MassHealth Accumulator Calculator 21

22 Remove Codes, Effective January 1, 2018 Code Description Limitation Action D5510 Repair broken complete denture Not allowed within 6 months of Remove Code base initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. D5610 Repair resin denture Not allowed within 6 months of Remove Code initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. D5620 Repair cast framework Not allowed within 6 months of initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. Remove Code 22

23 New Codes, Effective January 1, 2018 Code Description Limitation Fees Action D5511 Repair broken complete denture base, mandibular Not allowed within 6 months of initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. Under 21 $109 Adult $79 Add D5512 Repair broken complete denture base, maxillary Not allowed within 6 months of initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. Under 21 $109 Adult $79 Add 23

24 New Codes, Effective January 1, 2018 Code Description Limitation Fees Action D5611 Repair resin partial denture base, mandibular Not allowed within 6 months of initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. Under 21 $93 Adult $72 Add D5612 Repair resin partial denture base, maxillary Not allowed within 6 months of initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. Under 21 $93 Adult $72 Add 24

25 New Codes, Effective January 1, 2018 Code Description Limitation Fee Action D5621 Repair cast partial framework, mandibular Not allowed within 6 months of initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. Under 21 $121 Adult $97 Add D5622 Repair cast partial framework, maxillary Not allowed within 6 months of initial placement. All adjustments, repairs to acrylic or framework, as well as replacement and/or addition of any teeth to the prosthesis are considered part of the prosthetic code fee and are not billable. Under 21 $121 Adult $97 Add 25

26 New Codes, Effective January 1, 2018 Code Description Fee Action D9222 Deep Sedation / General Anesthesia- First 15 minutes Under 21 $109 Adult $73 Add D9239 Intravenous Moderate (Conscious) Sedation / Anesthesia- First 15 minutes Under 21 $101 Adult $84 Add 26

27 Codes to be Edited, January 1, 2018 Code Description Limitation Fees Action D9223 Deep sedation / general anesthesia- each additional 15 minute increment Under 21 $109 Adult $73 Edit D9243 intravenous moderate (conscious) sedation/analgesia each additional 15 minute increment Five of (D9243) per 1 Day(s) Per patient. Under 21 $101 Adult $84 Edit 27

28 Other Important Information 28

29 Third Party Liability Claims (TPL) Check member eligibility on the MassHealth Web Portal If member is eligible, click on member number to check if member has other primary insurance If a member has a primary insurance, you must submit the claim to the primary insurance(s) first All TPL claims must have an Explanation of Benefits (EOB) from the primary insurance, or a letter documenting the member s termination from the primary insurance, attached to the MassHealth claim, to prevent a claim DENIAL Primary EOB S must be submitted with the primary insurance name and logo on the EOB. Partial EOB s will not be accepted To download full EOB, your office must have the correct profile set on the primary payer s web site If the member s primary coverage terminates, the member must call MassHealth Customer Services ( ) to update their information 29

30 MassHealth Web Portal Resources- Related Documents Office Reference Manual (ORM) Fee Schedule Massachusetts W-9 Electronic Funds Transfer (EFT) Form for Direct Deposit Presentations, Newsletters, etc. MassHealth Dental Provider Web Portal Presentation 30

31 Bell Notifications *The Bell on Top Tool Bar Will Have a Red Dot When a New Notice Has Been Posted 31

32 Helpful Internet Links & Resources Provider Web Portal Check eligibility, submit authorizations & claims Vendor Web Use this to check on payment status NPPES Use to obtain, verify, and update NPI information Regulations Updates Sign-up to get notified of any changes in the regulations mailto: IVR/Call Center - (800) available 24 hours a day / 7 days per week 32

33 MassHealth Outreach Programs 33

34 Fluoride Varnish in a Medical Setting Integrate medical and dental care through the promotion of the fluoride varnish program. Provide training and guidance regarding the importance of oral health, applying fluoride varnish, the importance of age one visits and referral to a dental home. Provide support for the implementation of fluoride varnish application in the medical setting to include training, billing support and tools for referral. 31

35 Fluoride Varnish in a Medical Setting, continued Promoting Oral Health and Fluoride Varnish in Medical Offices 32

36 Collateral Material We ve expanded this program to include more tools and support for the medical offices as well as updated materials. Materials Available: o Baby Teeth Brochures o Educational Posters o New Survey 33

37 DentaQuest - Additional Resources Megan Mackin: Outreach Coordinator Phone: Megan.Mackin@DentaQuest.com Sean Moran: Provider Intervention Specialist Phone: Sean.Moran@DentaQuest.com Giovani Romero: Member Intervention Specialist Phone: Giovani.Romero@DentaQuest.com 37

38 Questions 38