Download Training - CareSource

CareSource
Dental Program
September 9, 2008
12:00 – 1:00
Welcome!
Introductions:
• Dr. Terry Torbeck, Vice President/Senior Medical Director
• Dr. Gary Ensor – CSMG Dental Consultant
• Cheryl Slagle, RN, CMCN, CCM
Director Medical Management
• Meloney Porter, RN Team Lead for Dental Services
• Candace Owens, Senior Dental Coordinator
Agenda
• Review Adult Dental Benefit changes
• Review communications sent to providers including
benefit and prior authorization changes
• Review CareSource prior authorization requirements and
benefits
• Overview of the CareSource Dental Handbook
Restored Adult
Dental Benefits
•
•
Adult dental benefits restored effective July 1, 2008
Restoration of the Medicaid adult dental benefits applies to all Ohio Medicaid Covered that was in place
until December 31, 2005.
Restored Adult
Dental Benefits
•
•
D0321
D1510
•
D1515
•
D1520
•
D1525
•
D2752
•
D2930
•
D2931
Other TMJ Films
Space Maintainer Fixed
Unilateral
Fixed Bilateral Space
Maintainer
Space Maintainer Removable
Unilateral
Space Maintainer Removable
Bilateral
Crown Porcelain w Noble
Metal
Prefab Stainless Steel Crown
Primary
Prefab Stainless Steel Crown
Perm.
•D2933 Prefab Stainless Steel Crown
•D2952 Post & Core Cast + Crown
•D3320 Root Canal Therapy bicuspids
•D3330 Root Canal Therapy molars
(Note: Root canals require PA if 3 or
more root canal procedures are
scheduled within 6 months).
•D3351 Apexification/recalcification initial visit
•D3352 Apexification/recalcification interim visit
•D3353 Apexification/recalcalcification final visit
•D3410 Apicoectomy/Periradicular Surgery Anterior
Restored Adult
Dental Benefits
•
D4210 Gingivectomy/Plasty Per Quad
D7471 Removal Exostosis Any Site
•
D7220
D7671 Alveolus Open Reduction
•
D7230 Impact Tooth Removal Partial Bony
•
D7240 Impact Tooth Removal Comp Bony
•
D7241 Impact Tooth Removal Bony w Comp
•
D7250 Tooth Root Removal
•
D7270 Tooth Reimplantation
•
D7280 Surgical Access Unerupted Tooth
•
D7310 Alveoplasty w Extraction
•
D7320 Alveoplasty wo Extraction
Impact Tooth Removal Soft Tissue
D7899
D7960
D7970
D8210
TMJ Unspecified Therapy
Frenulectomy/Frenulotomy
Excision Hyperplastic Tissue
Orthodontic Removable
Appliance Treatment
D8220 Fixed Appliance Therapy Habit
Y7255 Remove Supernumary Tooth
Dental Provider
Communication
• Mailed in mid July
• Outlined Medicaid restored adult dental benefits
• Defined CareSource prior authorization requirements
• Introduced the revised CareSource Dental Handbook
• Defined upcoming changes to the process for
Orthodontia management and billing
The following services require prior
authorization
•
•
•
•
•
•
D0321 Other TMJ Films
D2752 Crown Porcelain w
Noble Metal
D2952 Post & Core Cast +
Crown
D3320 Root Canal Therapy
bicuspids
D3330 Root Canal Therapy
molars
Note: Root Canals require PA if
3 or more root canal procedures
are scheduled within 6 months.
•
•
•
•
•
•
D3352 Apexification/
recalcificaiton interim visit
D4210 Gingivectomy/Plasty
Per Quad
D7240 Impact Tooth Removal
Comp Bony
D7241 Impact Tooth Removal
Bony w Comp
D7250 Tooth Root Removal
D7280 Surgical Access
Unerupted Tooth
The following services require prior
authorization
•
•
•
•
•
•
•
D7471 Removal Exostosis
Any Site
D7899 TMJ Unspecified
Therapy
D7960 Frenulectomy/
Frenulotomy
D7970 Excision Hyperplastic
Tissue
D8210 Orthodontic Removable
Appliance Tx
D8220 Fixed Appliance
Therapy Habit
Y7255 Remove Supernumary
Tooth
•
•
•
•
•
•
D5110 Complete Upper
Denture - Maxillary
D5210 Complete Lower
Denture - Mandibular
D5211 Maxillary Upper Partial
Denture - Resin Base
D5212 Mandibular Lower
Partial Denture - Resin
Base
D5213 Maxillary Upper Denture
Partial – Cast metal
D5214 Mandibular Lower
Denture Partial - Cast
metal
Orthodontia
•
As required by Ohio Administrative Code, coverage of comprehensive
orthodontics is limited to the most severe handicapping orthodontic
conditions.
•
Comprehensive orthodontics should be considered only after eruption of
permanent centrals, laterals, first molars and first premolars. Exceptions
can be made in the case of severe maxillary and / or mandibular growth
abnormalities.
•
Coverage is limited to patients younger than 21.
•
Only one course of comprehensive orthodontic treatment per person,
per lifetime is covered and is capped at a total dollar amount.
Orthodontia Changes
• Current CareSource orthodontia review policy will be in effect until
October 1, 2008.
• Beginning October 1, a two-step review process will be required.
• Please refer to pages 16-19 of the CareSource Dental Handbook for
detailed information.
Orthodontia Changes
• Step 1: Evaluation for Orthodontia Referral
– The referring dentist or orthodontist must submit a request for
orthodontic workup.
• Required Documentation:
– Orthodontic predetermination form
– A diagnostic complete set of radiographs OR a diagnostic panoramic
radiograph OR photos showing the patient's bite and occlusal view
– Any other supporting documentation
– If it is determined that the patient’s condition meets the established
CareSource/ODJFS guidelines as having the most severe
handicapping orthodontic condition, an authorization for a
comprehensive orthodontic workup will be given.
Orthodontia Changes
• Step 2: Orthodontic Workup
– If, after the orthodontic workup, the orthodontist believes the member
may meet the CareSource/ODJFS guidelines as having the most
severe handicapping orthodontic condition, the orthodontist must
submit a request for comprehensive orthodontic treatment.
• Required Documentation:
– A diagnostic complete set of radiographs OR a diagnostic panoramic
radiograph
– Properly trimmed study or computer models (preferred)
– Cephalometric films (D0340)-no tracings
– Lateral and frontal photographs of the patient with lips together
– Any other supporting documentation
Orthodontia Changes
• Step 2: Orthodontic Workup (cont.)
–If the request for comprehensive orthodontic
treatment is approved, an authorization will be
sent to the requesting provider which will
provide authorization for the entire course of
treatment (as long as the patient remains an
eligible CareSource member.
Orthodontia Changes
•
Beginning October 1, 2008 orthodontia reimbursement for maintenance
services will have the following changes:
– Monthly billing cycle (D8030 Monthly Orthodontic Treatment) instead of
quarterly for new starts only.
– For ease of billing, orthodontists can continue quarterly claims submission for
new patients by submitting 3 of the D8030 monthly charges if the patient was
enrolled and actively being treated during that quarter.
– The quarterly billing cycle (D8670 Quarterly Orthodontic Treatment) should be
continued for existing patients until their treatment is concluded.
Reimbursement
Per Ohio Administrative Code 5101:3-1-60 Medicaid reimbursement:
Payment for a covered service constitutes payment-in-full and may not be
construed as a partial payment when the reimbursement amount is less than
the provider’s charge. The provider may not collect and/or bill the consumer for
any difference between the payment and the provider’s charge or request the
consumer to share in the cost through a deductible, coinsurance, co-payment
or other similar charge.
Reimbursement
•
CareSource absorbs any member co-payments.
•
The cost of analgesic and local anesthetic agents is included in the
fees associated with covered dental services and is not reimbursed
separately.
Dental Handbook
•
CareSource Dental
Handbook
•
CareSource Dental
Handbook
•
CareSource Dental
Handbook
•
Questions