Online Claim Entry Dental Billing

1. Online Claim EntryDental Billing Presented by Xerox State Healthcare, LLC Provider Relations

2. Resources • When online use: Ask Service Representative • HIPAA.Desk.NM@xerox.com • NMPRSupport@xerox.com • Call Center 505-246-0710 or 800-299-7304 • New Mexico Web Portal • Provider Information section • Links and FAQ section • Provider Login section

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/2013.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. The Billing Process

6. Before you bill Medicaid • Check the recipient’s eligibility for Medicaid. • Check the recipient’s eligibility for dental services. • Check the recipient’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.

7. 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.

8. 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.

9. Eligibility Inquiry Date is required. Providers can now search by Date Span. The “SSN-Style” ID Number

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

11. 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)

12. Categories of Eligibility with Co-pays • Recipients the COE’s below may require co-pays for some services. • 071 – CHIP (Children’s Health Insurance Program) • 074 – WDI (Working Disabled Individuals)

13. CHIP Co-payment 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

14. 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.

15. CMS (Children’s Medical Services) Claims Submission • CMS is the same as billing for a Medicaid recipient with the following differences: • Always use the 14 digit CMS recipient 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.

16. Utilization Review (UR) • How do you determine if/when a PA is required? • Call Molina TPA at (505) 348-0311 (in Albuquerque) (866) 916-3250 (toll free). Molina TPA can assist with PA requirements and procedures.

17. 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.

18. Prior Authorization RequirementsFee for Service (FFS) • 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

19. Prior Authorization RequirementsFee for Service (FFS) • Indicate Prior Authorization at the top of the ADA form. • Do not list Date of service. • If date of service or no indication is made at  the top or the form, the form maybe mistaken for a dental claim submission.

20. Prior Authorization RequirementsFee for Service (FFS) • Recommended Steps for Provider Inquiries Regarding the Status of a FFS Dental Prior Authorization: • Check the New Mexico Medicaid Web Portaland 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.

21. Prior Authorization RequirementsFee for Service (FFS) • 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 the Xerox provider Relations Helpdesk at 800-299-7304. • 5. 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 recipients that have questions regarding PA status, please refer them to Molina Healthcare Dental Care Coordinator, Christopher Salazar at (505) 348-0279.

22. 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

23. 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.

24. 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).

25. 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.

26. 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. 

27. 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%20CODE%20FEE%20SCHEDULE.pdf

28. 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

29. 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

30. 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.

31. 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.

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

33. ADA Claim Form Requirements

34. 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

35. 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 recipient 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.

36. 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.

37. Timely Filing Denials • Re-filing Claims and Submitting Adjustments • Online Claim Entry ADA Dental Claim Form: • Enter the TCN number in “Timely Filing TCN” field

38. ADA 2006 Dental Online Claims Entry

39. ADA 2006 Claim Submission • 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://nmsyst.acs-shc.com/static/PDFs/Medicaid%20Publications/ClaimFormInstr/ADA%202006%20Dental%20Form%20instructions.pdf 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.

40. Where to get a copy of claim form instructions Click Forms , Publications, and Instructions under Provider Information

41. Where to get a copy of claim form instructions Scroll down Open file

42. ADA Dental Online Claims Entry Please note template are limited to 25 per user. HINT: think about use procedure code, or dates (billing range dates) The best time to directly enter your claim is Sunday through Friday between the hours of 6 a.m. - 6 p.m. (MST). Claims entered by Friday 6 pm could be adjudicated and reflect as early as Monday on your Remittance Advice.

43. ADA Dental- Primary Example

44. ADA Dental- Primary Example Select “None” for Primary Dental Claims

45. ADA Dental- Primary Example Claim Information Indicate PA# and/or Timely Filing TCN Complete all applicable fields New fields are based on the ADA 2012 Claim Form, and are not mandatory fields.

46. ADA Dental- Primary Example Attachments

47. ADA Dental- Primary Example Line Item Information New fields are based on the ADA 2012 Claim Form, and are not mandatory fields. Treating Provider ID Treating Provider NPI

48. ADA Dental- Primary Example Indicate the Total Charge

49. TPL Billing Instructions • Indicate “Other insurance” in the “Other Insurance Info” section of claim. • Attach a copy of the EOB from the other insurance. Always attach the list of EOB code explanations from the other carrier. • Prior Payment Amount field needs to be filled in with the paid amount from the primary payer.

50. TPL Example 120.00 Select “ Other Insurance” for Dental TPL submissions