Dental Billing

3. The Billing Process Check eligibility Get Prior Authorization (only if required) Claim Submission Review Remittance Advice Resubmit, Void, or Adjust

4. Check eligibility and 0101 – Service Dates Within Managed Care Enrollment Period 0141– Client ID not on file 0143 - Client not Eligible 0222 – Name/DOB Mismatch ** Common Denial** 0029 – Service not Family Planning

5. Limited Categories of Eligibility 029 – Family Planning 035 – Pregnancy Related 041, 044 – Qualified Medicare Beneficiary (QMB) - MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid. If service is not covered by Medicare, MEDICAID WILL NOT PAY

6. Co-pays 071 – SCHIP (State Children’s Health Insurance Program) 074 – WDI (Working Disabled Individuals) Clients with these COEs may owe co-pays for some services.

9. TPL – Third Party Liability Medicaid is the payer of last resort, except for clients covered by Indian Health Services (IHS.) TPL is all commercial insurance Medicaid does not consider Medicare TPL The TPL must be billed primary to Medicaid

10. 0750 – Client has TPL - Resubmit with TPL EOB When a client has TPL you must submit to the private insurance company as primary. Once you have received the EOB, you need to submit to Medicaid as secondary. You have 1 year from the DOS to submit the claim to Medicaid.

11. Ways to Check Eligibility Medicaid Eligibility Verification Services (MEVS) – See handout for list Automatic Voice Response System (AVRS) – (505) 246-2219, (800) 820-6901 Eligibility Help Desk – (505) 246-2056, (800) 705-4452

12. Eligibility Check List Date of Service – Make sure client is eligible on DOS Is the Client Fee for Service or SALUD Limited Benefits – Check Category of Eligibility TPL or Medicare – There may be a payer primary to Medicaid The Client may be required to pay a copay

13. The Billing Process Check eligibility Get Prior Authorization (only if required) Claim Submission Review Remittance Advice Resubmit, Void, or Adjust

14. Prior Authorization How do you determine if/when a Prior Authorization (PA) is required? Call Utilization Review/BCBS – 1-800-392-9019 UR can tell you if a PA is required and the procedures for getting a PA

15. Prior Authorization All claims for CMS clients must be accompanied by prior authorization from CMS

16. The Billing Process Check eligibility Get Prior Authorization (only if required) Claim Submission Review Remittance Advice Resubmit, Void, or Adjust

17. Advantages to Billing Electronically Provider has complete control over data entry Provider receives claim status (Paid/Denied/ Suspending) in as little as a week Provider receives payment in as little as a week Provider has a confirmed receipt of the submitted claims Eliminates expense of mailing claims for the provider

18. Claim Submission Electronic or paper (HCFA 1500) – any claim within 120 days from first date service with no “special” attachments Paper – any claim (HCFA 1500) always requiring attachments or claims over 120 days from first date of service with proof of timely filing

19. The Client Detail functional group is used to capture and display information required for enrolling clients in the New Mexico Medicaid Program and maintaining information related to clients. All of the tasks performed within this functional group originate with the Client Detail Selection window. The information retrieved from the subsequent tab page windows is displayed consistently for all clients. [Click to next slide] The Client Detail functional group is used to capture and display information required for enrolling clients in the New Mexico Medicaid Program and maintaining information related to clients. All of the tasks performed within this functional group originate with the Client Detail Selection window. The information retrieved from the subsequent tab page windows is displayed consistently for all clients. [Click to next slide]

20. Filling Out the Dental Form

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23. The Client Detail functional group is used to capture and display information required for enrolling clients in the New Mexico Medicaid Program and maintaining information related to clients. All of the tasks performed within this functional group originate with the Client Detail Selection window. The information retrieved from the subsequent tab page windows is displayed consistently for all clients. [Click to next slide] The Client Detail functional group is used to capture and display information required for enrolling clients in the New Mexico Medicaid Program and maintaining information related to clients. All of the tasks performed within this functional group originate with the Client Detail Selection window. The information retrieved from the subsequent tab page windows is displayed consistently for all clients. [Click to next slide]

24. The Client Detail functional group is used to capture and display information required for enrolling clients in the New Mexico Medicaid Program and maintaining information related to clients. All of the tasks performed within this functional group originate with the Client Detail Selection window. The information retrieved from the subsequent tab page windows is displayed consistently for all clients. [Click to next slide] The Client Detail functional group is used to capture and display information required for enrolling clients in the New Mexico Medicaid Program and maintaining information related to clients. All of the tasks performed within this functional group originate with the Client Detail Selection window. The information retrieved from the subsequent tab page windows is displayed consistently for all clients. [Click to next slide]

25. Prior Authorization number goes in Box #2. Do not send pre-treatment determination estimates to ACS. Do not send x-rays to ACS. For prior authorization procedures, call UR/BCBS at 1(800) 392-9019

26. Boxes 3, 4 & 5: ACS’ information - name, address, etc.

27. “Patient” - This is the area where all of the patient’s information is entered. Name, date-of-birth, sex, and Medicaid ID number are required. “Patient ID #” is the Medicaid ID number. This should be entered in box #13. Remember, each Medicaid client has their OWN ID number.

28. If your software fills out the client’s Medicaid ID number in the “subscriber/employee” area, ACS and MAD have made arrangements to accommodate this. If there is an invalid client ID in box 13, then your claim will deny for “client ID on claim but not on file”.

29. “Subscriber/Employee” - It is not necessary to fill out the “subscriber/employee” information on the claim. It is a repeat the information in “patient” area. “Other Policies” - Only enter information in this area if the client is covered by commercial insurance. Otherwise, just check the “no” box.

30. “Billing Dentist” - Enter your NM Medicaid provider information in this area. In Box #44 - “provider ID#” - enter the “pay-to” provider’s NM Medicaid ID number. This is the provider to whom the payment from Medicaid will be issued.

31. #58 - Diagnosis Codes - Diagnosis codes are not required on dental claim forms #59 - Enter service information here: enter the date enter the tooth number: valid “numbers” are A thru T and 1-32. Use the valid HIPAA standard supernumerary tooth codes when billing for services for DOS starting 1/1/04. SN is not valid. The quadrant or oral cavity code must be entered in the tooth number field unless the dental claim form has a field for oral cavity code.

32. Surface - enter valid tooth surfaces here. Up to 6 can be entered. Valid surfaces are: B - Buccal D - Distal F - Facial I - Incisal L - Lingual M - Mesial O - Occlusal

39. The Billing Process Check eligibility Get Prior Authorization (only if required) Claim Submission Review Remittance Advice Resubmit, Void, or Adjust