Dental Details A Z Indian Health Provider Training 2012 Agenda - PowerPoint PPT Presentation

Dental Details A – Z Indian Health Provider Training 2012

Agenda  Meet the Dental Prior Authorization Team  Dental Statistics  Policy  Orthodontic Referrals

Dental Prior Authorization Team  Dr. Leon Bragg – Chief Dental Officer  Dr. Richard Gilman – Orthodontic Consultant  Tracy Matthews – Dental Programs Coordinator  Dana Shepard – Dental Analyst II, Orthodontics  Sara Gillum – Dental Analyst II, General Dental  Wendy Payne – Dental Analyst II, General Dental  Linda Taylor – Administrative Assistant II, Orthodontics  Lisa Jack – Administrative Assistant I, General Dental

Did You Know?  Approximately how many members does SoonerCare serve? – 266,363 Adults – 498,352 Children  How many participating dental providers in SoonerCare? – 1,015  How many Prior Authorizations were processed for 2011? – 43,417

Dental Policy WWW.OKHCA.ORG Chapter 30, Subchapter 5, Part 79 Dental Specific Encounters Policy WWW.OKHCA.ORG Chapter 30, Subchapter 5, Part 110

Dental Coverage for Adults  Emergency Extractions – Legislative intent allows for removal of teeth for relief of pain and infection.  Smoking & Tobacco Use Cessation Counseling  Medical Surgical Services may be allowable

Dental Coverage for Special Adult Populations  Adults residing in Intermediate Care Facilities for the Mentally Retarded (ICF/MR); receive services similar to children  DDSD Waiver Services; all must be prior authorized through DDSD; requires a special contract  Pregnant women may have additional limited services; must be enrolled in Perinatal Dental Access Program (PDEN)

PDEN Covered Codes In addition to dental services covered for adults, other services  available include: D0120, D0150  D0220, D0230  D0272, D0274  D1110, D1204,  D2140, D2150, D2160, D2161  D2330, D2331, D2332, D2335  D2391  D4341, D4342  D9230  ** Prior authorization is NOT required for this program ** 

Policy Basics  Comprehensive Oral Evaluation  Periodic Oral Evaluation  Emergency/Limited Oral Evaluation  X-Rays  Dental Sealants  Stainless Steel Crowns  Pulpotomy or Pulpectomy  Anterior Root Canals  Interim Partial Dentures

Policy Basics  The need for prior authorization is rare for your facilities, however……..  All reimbursable dental services provided during an encounter must follow the guidelines of OHCA policy.  Dental records are subject to post payment review to determine alignment with OHCA policy.

Dental Specific Encounters Policy  317:30-5- 1098(B) “OHCA will cover one dental encounter per member per day regardless of how many procedures are done or how many providers are seen UNLESS……  …..if due to an emergency, the same member returns on the same day for a second visit and has a different diagnosis. Then, a second encounter is allowed.”

Dental Encounter Claims  Dental encounter claims are to be filed on the UB04 claim form  Revenue code 512

Prior Authorization  Send all Prior Authorization requests directly to the Dental Unit; electronic submissions are not available at this time – OHCA – Dental Unit 2401 NW 23 rd St., Suite 1-A Oklahoma City, OK 73107  All prior authorization requests are filed on the currently approved ADA form

Orthodontic Services Eligibility for SoonerCare Orthodontic Services  Member must have a referral from a primary care Dentist (Form DEN-2)  Score a minimum of 30 on the HLD  Be under the age of 18  See policy for further restrictions

Secure Site How to obtain Dental History

The Dental Inquiry can be found here or under the Claims link at the top.

Enter the Member ID Enter Procedure Code if checking for Specific Code

Contact Us  Prior Authorization – Dental Unit (405)522-7401  Claims, Eligibility, Policy, Internet Help Desk, Third Party Liability, or Provider Contracts – (800)522-0114 or – (405)522-6205