Transcript Dental Billing - New Mexico Medicaid Portal

Dental Billing
Presented by:
Xerox State healthcare, LLC
Provider Relations
Resources
When online use: Ask Service Representative
[email protected]
[email protected]
Call Center 505-246-0710 or 800-299-7304
New Mexico Web Portal
• Provider Information section
• Links and FAQ section
• Provider Login section
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
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Important State Websites - Dental
Dental Fee Schedule:
http://www.hsd.state.nm.us/mad/pdf_files/FeeSchedules/DENTAL%20CO
DE%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
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The Billing Process
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.
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.
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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.
Eligibility Inquiry
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.
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)
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)
CHIP Copayment Schedule
Service
Outpatient Physician Visit
Urgent Care Visit
Outpatient Therapy Visit
Other Practitioner Visit
Dental Office Visit
Co-payment
$5.00
$5.00
$5.00
$5.00
$5.00 - co-pay does not
apply if service is
preventative, diagnostic, or
orthodontic.
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 copayment requirements.
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.
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.
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.
Prior Authorization Requirements
FFS (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
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Prior Authorization Requirements
FFS (Fee for Service)
Recommended Steps for Provider Inquiries Regarding the Status of
a FFS Dental Prior Authorization:
1. Check the Xerox web portal and confirm the PA numbers.
2. If there is no PA on the web portal, contact DentaQuest at (800) 3418478 for the status.
3. 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.
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Prior Authorization Requirements
FFS (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.
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 clients that have questions regarding PA status, please
refer them to Molina Healthcare Dental Care Coordinator, Christopher
Salazar at (505) 348-0279.
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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%20dra
ft%20dental%2002%2010%202010%20rev.pdf
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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.
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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).
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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.
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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.
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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
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
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
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.
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.
Service Limits – X-Rays
Full mouth or panoramic x-rays are covered once every 3 years.
Claim Form Requirements
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
[email protected]
or call 800-299-7304
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%2
0to%20ACS%20EDI.pdf
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.
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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.
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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.
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ADA 2006 Dental Claim
Submission
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.
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.acsinc.com/nm/general/loadstatic.do;jsessionid=QhtBzkNyVLD02LTWGGww
y5zJvZYpfjdl5hpGxQQBjTYy027ChpYJ!1711986351?page=ProviderInfor
mation.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.
Where to get a copy of claim form instructions
Click Forms ,
Publications, and
Instructions under
Provider Information
Where to get a copy of claim form instructions
Scroll down
Open file
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.
TPL Example
120.00
paid amount from the
primary payer.
45 00
120 00
Co-pay Billing Instructions
The NM Medicaid program requires a prior payment made by a primary
payer to be entered in this field.
• If trying to collect a flat copayment amount, the amount entered in box
#32
• should be the difference between the total billed and the copayment
amount.
• Write “HMO Copayment due” on the claim.
Co-pay Billing Instructions
• Leave blank if there is not a primary payer or if the primary payer did
not make a payment on the claim.
*Note: Do not enter previous amounts paid by Medicaid on these services.
• Claims partially paid by Medicaid need to be submitted as adjustments
when trying to collect for the unpaid or partially paid services on the
claim.
Co-pay Example
120.00
Difference between the total billed
and the copayment amount. ($20
copay)
100.00
120.00
Billing Instructions - Reminder
Rendering NPI number is always required!
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Common Denials
0101 – Service Dates Within
Managed Care Enrollment Period
The client is in managed care on some or all of the dates of service on the
claim.
•
Verify eligibility through our Web Portal or AVRS and resubmit to the
appropriate MCO.
1361 – Exact Duplicate
Payment has already been made for this claim
•
Check the Web Portal under Claim Status to view the claim history to
identify when the claim was paid and post it to your accounts.
•
If there is an incorrect payment because of a billing error, you must
submit an Adjustment Request Form along with your corrected claim
form in order to have the claim corrected.
0820 – Timely Filing Limit Not Met
.
The initial filing limit has not been met. Please make sure to do the
following:
• Verify that the claims was/ was not submitted within the timely filing
limit.
• If the claim needs a reconsideration for timely filing, make sure to resubmit with a cover letter explaining the reasons that timely filing may
need to be overridden.
0424 – Billing Provider Not Enrolled
on Dates of Service
Provider enrollment status is not active.
The provider can contact the provider enrollment department for
additional assistance at:
505-246-0710 or 800-299-7304
1699 – Must Submit Claim Electronic
The provider submitted a paper claim and the provider master database
media code does not contain a value of “P” – Paper.
• The provider must submit all claims electronically.
0431 – Procedure Not A Covered
CMS Service for Dates of Service
The procedure is not a covered CMS service for the date of service.
0124- From Date of Service is
Missing
• Please review the Dental Form instructions for Box 24 and submit
accordingly.
0110- Service dates Within Coordination
of Long Term Services Enrollment Period
• Client is enrolled in a Colts MCO.
• Provider can verify Colts MCO, via New Mexico Medicaid web portal.
0439 – Procedure not a Benefit for
Service Date
Verify that claim was processed with correct procedure code ( box 29).
Call provider relations helpdesk, for additional assistance at:
505-246-0710 or 800-299-7304
0362- Tooth Surface Required
The “Tooth Surface” box is empty and the procedure code requires a tooth
surface.
Enter a valid tooth surface here
• O – Occlusal is the only surface covered.
Provider Enrollment Tips
Most Common Mistakes Applications
•
Placing “same” in a box
•
Not answering a yes/no answer question
•
Missing initials on each page, including the signature page
•
The mailing and billing addresses not matching the group on a MAD 312 app
•
Not putting in a provider type and/or specialty.
•
Not initialing next to the questions on the signature page
•
Not including a complete document when a provider declares a ‘yes’ answer on the
signature page.
Not having insurance for the provider that proves insured while they are working for or at
the group listed in box 24 of a MAD 312
•
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Most Common Mistakes Applications
•
Not initialing next to the questions on the signature page
•
Not including a complete document when a provider declares a ‘yes’ answer on
the signature page.
•
Not having insurance for the provider that proves insured while they are
working for or at the group listed in box 24 of a MAD 312
•
Not signing in the correct spot on a MAD 335.
•
Not initialing any strike thru they make on the app.
•
Using white out / line out
•
Faxing an application.
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Most Common Mistakes – TAD’s
• Not completing the ownership pages for all listed as required
• Providers believe that non-profit status exempts them from completing
the ownership sections (this includes ss#s and b-dates). There is
nothing on the doc that exempts them based on profit status.
• Not including a complete document when a provider declares a ‘yes’
answer on the signature page. We need the document to include all
aspects as outlined on the TAD; we cannot use a quick sentence
written in under the question.
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Most Common Mistakes – TAD’s
• Providers changing a document to match another
person/business. The document belongs to the person/business it is
printed for and identified by the provider number on it. You cannot alter
mine to update yours.
• Using white out / line out.
• Providers need to print the name of the person signing the doc above
their signature, especially if their signature isn’t legible.
• Providers need to initial next to three questions on signature page.
• Providers cannot fax a TAD.
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Most Common Mistakes – Updates
• Using / completing an application to cross reference an active provider
to a group.
- Applications are for applicants, if you’re already active we just
need a letterhead letter signed by all parties involved, proof of
license and insurance, DEA if using it.
• New W-9’s will not get your addresses changed.
• Xerox cannot make changes over the phone.
• Xerox cannot process multiple people on one letter.
-If you’re going to disaffiliate several people from your group, each
one needs their own letter.
• Include provider numbers on all correspondence.
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Resources
When online use: Ask Service Representative
[email protected]
[email protected]
Call Center 505-246-0710 or 800-299-7304
New Mexico Web Portal
• Provider Information section
• Links and FAQ section
• Provider Login section