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Dental Billing

Dental Billing. Presented by Mina Reynaga & Kristen Brice Provider Field Representatives. Contact Xerox. Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL.

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Dental Billing

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  1. Dental Billing Presented by Mina Reynaga & Kristen Brice Provider Field Representatives

  2. Contact Xerox Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL. • For all contact, Claims, and Correspondence Addresses information go to the following link on the New Mexico Medicaid Web Portal: • https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do?page=ContactUs.htm • Email: NMPRSupport@xerox.com

  3. Important State Websites - Dental • Dental Program Policy: • http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83107.pdf • Dental Provider Billing Instructions: • http://www.hsd.state.nm.us/mad/pdf_files/BillingInstructions/83107.pdf • Registers and Supplements: • http://www.hsd.state.nm.us/mad/registers/2012.html

  4. Important State Websites - Dental • Dental Fee Schedule: • http://www.hsd.state.nm.us/mad/pdf_files/FeeSchedules/DENTAL%20CODE%20FEE%20SCHEDULE.pdf • Providers can find a copy of a HLD Index Scoring Sheet, at the link below: • http://www.hsd.state.nm.us/mad/pdf_files/Forms/NM%20HLD%20Form%200000.pdf

  5. Xerox Field Representative Provider Field Representative: • Mina Reynaga (505)246-9988 Ext. 813233Kristen Brice Ext. 8131216 • E-mail: Erminia.reynaga@Xerox.com • E-mail: Kristen.brice@Xerox.com • Cc: NMPRSUPPORT@Xerox.com

  6. The Billing Process

  7. Before you bill Medicaid • Check the beneficiary’s eligibility for Medicaid. • Check the beneficiary’s eligibility for dental services. • Check the beneficiary’s service limits. • Check the procedure code on the dental fee schedule to determine if prior authorization is needed. • Check for other dental insurance coverage.

  8. Before you bill Medicaid • Check the procedure code on the fee schedule to see if New Mexico Medicaid covers that code. • Check the current version of the ADA’s Current Dental Terminology code book for correct procedure codes. • Check to see if the procedure code requires tooth, surface, or quadrant indicators. • Check to see if co-payment is required.

  9. Ways to Check Eligibility • On-Line Eligibility Inquiry—Web Portal • https://nmmedicaid.acs-inc.com • Automatic Voice Response System (AVRS) (800) 820-6901 • Xerox Eligibility Help Desk: (800)-705-4452 • Monday - Thursday 8:00 a.m. - 5:00 p.m. • Friday (Mountain Time) 8:00 a.m. - 4:00 p.m.

  10. Eligibility Inquiry

  11. Eligibility Inquiry – UPDATE w/ Dental Slide TPL

  12. Eligibility Denials • What do I do if I receive a denial pertaining to the client’s eligibility? • Verify client eligibility for the date of service on the Web Portal. • Verify correct patient ID, DOB and Name. • Attach an authorization (CMS 309), if CMS client.

  13. Dental services are not covered under these categories: • 029 – Family Planning • 035 – Pregnancy Related (NAX) when patient is exempt from a SALUD plan. • 035 (2) – Premium Assistance for Maternity (PAM) • 041, 044 – Qualified Medicare Beneficiary (QMB) • 062, 063 – State Coverage Insurance (SCI) • 072 (2) – Premium assistance for Kids (PAK)

  14. Categories of Eligibility with Co-pays • Clients with these COE’s may owe co-pays for some services. • 071 – CHIP (Children’s Health Insurance Program) • 074 – WDI (Working Disabled Individuals)

  15. CHIP Copayment Schedule Service Co-payment $5.00 $5.00 $5.00 $5.00 $5.00 - co-pay does not apply if service is preventative, diagnostic, or orthodontic. • Outpatient Physician Visit • Urgent Care Visit • Outpatient Therapy Visit • Other Practitioner Visit • Dental Office Visit

  16. WORKING DISABLED INDIVIDUAL (WDI) CO-PAY AMOUNTS • $7.00 outpatient therapy and behavioral health services • $20.00 emergency room services $30.00 inpatient hospital services. • $7.00 doctor visit, urgent care or vision visit • $7.00 dentist visit • $5.00 prescriptions • Please note: Native Americans are exempt from CHIP and WDI co-payment requirements.

  17. CMS (Children’s Medical Services) Claims Submission • CMS is the same as billing for a Medicaid client with the following differences: • Always use the 14 digit CMS client ID number that begins with 07. • Always enter the PA number in box 2 of the ADA form (if the PA number is 8 digits, add 2 zeroes in front of it). • When submitting on paper, always attach the 309 form or copy of the Healthier Kids card.

  18. Utilization Review (UR) • How do you determine if/when a PA is required? • Call the UR Agency Molina TPA at (505) 348-0311 (in Albuquerque) (866) 916-3250 (toll free). • Provider Relations Helpdesk (800) 299-7304 • Molina TPA can tell you if a PA is required and the procedures for getting a PA.

  19. Prior Authorization Requirements • Services requiring a PA include but are not limited to the following: • Children’s benefits: Periodontics, braces, crowns, crown repair, root canals, maxillofacial prosthetics, certain maxillofacial repair services. • Adult benefits: Periodontics, dentures/partials and root canals (front teeth only), maxillofacial prosthetics, certain maxillofacial repair services.

  20. Prior Authorization RequirementsFFS (Fee for Service) • Important Information for Fee for Service Dental Services: • Prior authorization (PA) requests for dental services for FFS Medicaid recipients must be submitted to DentaQuest at the address listed below.  PA requests are submitted on the ADA form (appropriate ADA codes and tooth numbers/quadrants must be indicated) with appropriate documentation and clinical material, such as x-rays, charting, and study models for orthodontia.  • DentaQuest • 12121 North Corporate Parkway • Mequon, WI 53092 • http://dentaquest.com

  21. Prior Authorization RequirementsFFS (Fee for Service) • Recommended Steps for Provider Inquiries Regarding the Status of a FFS Dental Prior Authorization: • Check the Xerox web portal and confirm the PA numbers. • If there is no PA on the web portal, contact DentaQuest at (800) 341-8478 for the status. • If you have contacted DentaQuest for a status check and are not able to view the PA on the Xerox web portal, or more information is needed on the PA, contact Molina Healthcare Third Party Assessor Dental Care Coordinator toll-free at (800) 580-2811, ext. 180279 or in Albuquerque at (505) 348-0279 to resolve the issue.

  22. Prior Authorization RequirementsFFS (Fee for Service) • Recommended Steps for Provider Inquiries Regarding the Status of a FFS Dental Prior Authorization ( Continued): • 4. If you have questions about a dental claim denial, contact Molina Healthcare Third Party Assessor Dental Care Coordinator toll -free at (800) 580-2811, ext. 180279 or in Albuquerque at (505) 348-0279. • If after you have followed steps 1-4 (above) and issues are still unresolved, please contact Medical Assistance Division Staff Manager, Devi Gajapathi at (505) 827-6227. • 6. If you have clients that have questions regarding PA status, please refer them to Molina Healthcare Dental Care Coordinator, Christopher Salazar at (505) 348-0279.

  23. Orthodontic Authorizations • To ensure your orthodontic authorizations are processed efficiently and timely, we would like to remind you of the appropriate way to submit orthodontic authorization requests. Per New Mexico Medical Assistance Division Utilization Review instructions 8.310.7 UR Dental Services: • http://www.hsd.state.nm.us/mad/pdf_files/provmanl/8%20310%207%20UR%20draft%20dental%2002%2010%202010%20rev.pdf

  24. Orthodontic Authorizations • The documentation required must include each of the following: • Diagnostic Casts or digital study models  • Full mouth or panoramic x-ray • Cephalometric film  • Diagnostic Photographs • A completed orthodontic screening form that states the Handicapping Labiolingual Deviation Index (HLD) score and indicates the handicapping malocclusion. The provider may submit either the original or a copy.

  25. Orthodontic Authorizations • Prior to making a decision, DentaQuest may issue a request for information (RFI) to the provider requesting clarification or additional information, in order to have sufficient information to render an appropriate decision. • The provider must submit the clarification or additional information within 21 calendar days of issuance of the request or a technical denial may be issued (8.350.2 NMAC).

  26. Orthodontic Authorizations • If your office needs the models returned please include a postage paid container, appropriate to securely return the ortho models or a postage paid label that we can apply to a container that we have available.

  27. Orthodontic Authorizations • As a reminder, you can receive 24 hour service 7 days a week by using www.dentquestgov.com to check member eligibility, history, submit claims, authorizations and many other features.  • Should you need other assistance, or wish to use our interactive voice response system, please contact DentaQuest at 1.800.483.0031. 

  28. Procedure Codes and Fee Schedule • Procedures must be reported using the American Dental Association’s dental procedure codes and terminology. For complete code descriptions, terms and definitions, reference the Current Dental Terminology manual. • NM Medicaid Dental Fee Schedule is available: http://www.hsd.state.nm.us/mad/pdf_files/FeeSchedules/Dental_Codes.pdf

  29. Procedure Codes and Fee Schedule • Dental services must be billed with a “D” and a four digit code. • Oral cavity designations for quadrants are as follows: • 10 – UR • 20 – UL • 30 – LL • 40 - LR

  30. Service Limits – Children’s Services • Certain services are limited in frequency: • Two dental exams per year • Two cleanings every six months • Two fluoride treatments per year • Sealants: • Not covered on pre-molars • Only pay for sealants once every five years • O – Occlusal is the only surface covered

  31. Service Limits – Adult Services • Certain services are limited in frequency: • One dental exam per year • One cleaning per year • Adults are not eligible for braces or crowns.

  32. Service Limits – Dentures and Partials • Dentures and partials require PA • Payment include 2 adjustments during the first 6 months after delivery. • Adjustments are limited to 2 per year. • Repairs are limited to 2 per year for full and partial dentures. • Relining dentures is limited to once every 3 years. • Relining cannot be billed during the six months following the insertion of the prosthesis.

  33. Service Limits – X-Rays • Full mouth or panoramic x-rays are covered once every 3 years.

  34. Claim Form Requirements

  35. Electronic Claim Submission • All Fee For Service claims within 90 days from the initial date of service that do not require an attachment for payment must be submitted electronically. • For any assistance regarding Electronic Claims Submissions, contact the HIPAA Helpdesk • HIPAAHelpdesk@acs-inc.com • or call 800-299-7304

  36. Three Ways to Submit Claims Electronically • Payerpath – Free HIPAA Compliant web-based claims entry system. • The URL to the registration form for Payerpath submissions is: • http://www.hsd.state.nm.us/mad/hipaa.html • *Pay attention to the RA Newsletter, for upcoming updates to the Payerpath. • Through a Clearinghouse • EDI Gateway • The URL for additional information regarding EDI Gateway electronic submissions is: • http://www.hsd.state.nm.us/mad//pdf_files/Converting%20from%20TIE%20to%20ACS%20EDI.pdf

  37. Timely Filing Denials • Exceptions to the filing limit: • When the provider was not originally enrolled as a MAD provider on the date of service, the filing limit of 90 days is counted from the date the provider was notified of their enrollment, but must not exceed 210 days from the date of service. A provider should submit a provider participation agreement in sufficient time to allow processing and still meet the Medicaid 210 day limit for submitting the claim. • When a claim previously paid by a Medicaid managed care organization is recouped from a provider due to retroactive disenrollment of the client from the managed care organization, the filing limit of 90 days is counted from the date of the managed care organization’s notice or recoupment from the provider.

  38. Timely Filing Denials • Re-filing Claims and Submitting Adjustments • When resubmitting a claim or requesting an adjustment on a claim that is past the 90 day filing limit but originally met the filing limit, the “TCN” number which appears on the remittance advice (RA) will be used by Xerox to evaluate the claim. The provider must supply that TCN number in order for Xerox to be able to evaluate the claim.

  39. Timely Filing Denials • Re-filing Claims and Submitting Adjustments • ADA 2006 Dental Claim Form: • Enter the TCN number in Box 35 beginning on the left side.

  40. ADA 2006 Dental Claim Submission

  41. ADA 2006 Claim Form Requirements • All claims that do not require an attachment for payment must be submitted electronically. • Professional claims are submitted on the 837D electronically and the ADA-2006 on paper. • MAD requires that all paper ADA-2006 claim forms be on the original red claim forms. • Photocopies of claim forms will be returned to your billing office.

  42. ADA 2006 Claim Submission • The following claim is how a paper ADA 2006 claim form is generally filled out. • Use procedure codes that are specific to your claims. • You can get a copy of the ADA 2006 Claim form instructions for Medicaid requirements. https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do;jsessionid=QhtBzkNyVLD02LTWGGwwy5zJvZYpfjdl5hpGxQQBjTYy027ChpYJ!1711986351?page=ProviderInformation.htm • This will give you box by box information on how to fill out the claim form for Medicaid primary, TPL primary, or HMO/PPO primary claim variations.

  43. Where to get a copy of claim form instructions Click on Provider Information

  44. Where to get a copy of claim form instructions

  45. TPL Billing Instructions • Always attach a copy of the EOB from the other insurance. Always attach the list of EOB code explanations from the other carrier. • Box 32 needs to be filled in with the paid amount from the primary payer.

  46. TPL Example 120.00 paid amount from the primary payer. 45 00 120 00

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