WYOMING MEDICAID SEVERE MALOCCLUSION PROGRAM UPDATES Effective September 1, 2014
REFERRAL CHANGES (ages 12-18) D8660- Initial Consultation $75.00 No LOA is required for scheduling or billing General/Pediatric dentist can refer with no State form General/Pediatric dentist will be educated on criteria Orthodontists may see walk-ins
REFERRAL CHANGES (under 12) If a client, under the age of 12, has a condition that is in immediate need of orthodontic attention, the dentist may refer the child to the program The dentists must fill out the “Referral to SM program- Under 12” form and send it in to the State The referral must include the “medical necessity” reason in the narrative section The State will issue an LOA to the orthodontist to see the child early if medical necessity is present
Orthodontic Staff’s Responsibilities Schedule the consultation • Verify eligibility • * Medicaid current * Age of child * 1/Lifetime benefit To verify call: • 1-888-863-5806 Dental Services You will need to ask the rep if the child is currently eligible for Medicaid and if they have ever had the D8660 NOTE: The D8660-Initial Consultation is a 1/Lifetime benefit. It this has been billed before the child is not eligible for another consultation.
Doctor’s Responsibility General/Pediatric Orthodontist Review set criteria for the For walk-in clients, pre- 1. 1. SM program screen for criteria Only refer clients who have Only take records on clients 2. 2. a qualifying criteria who meet a set criteria Use parent handout to Use parent handout to 3. 3. explain to parent why their explain to parent why child is not being referred records will not be taken
If an orthodontist is being sent children who do not meet the set qualifying criteria, the Program manager should be contacted. 307-777-8088 The Program manager will reach out to the office and review the guidelines for referrals.
QUESTIONS ON REFERRALS?
BILLING CHANGES – D8660 No LOA required for D8660- Initial Consultation Submit claim to Wyoming Medicaid for D8660 with no LOA attached* *If the child is under the age of 12, an LOA is still required but does not have to be attached to the claim
BILLING CHANGES- D8080,D8090 If the client is approved for treatment, an LOA will be issued to the provider The provider must sign and return this LOA to the Program manager in the envelope provided and keep a copy for your records NOTE: Claims cannot be paid until the LOA is sent back Once the child is banded, the D8080 or D8090 can be billed to Wyoming Medicaid with no LOA attached
BILLING CHANGES- D8670 There are no changes to how the quarterly D8670 claims are billed by dates of service Please continue to list each date of service the child was seen in the office for adjustments, repairs, or any other services (this is required by federal guidelines) When sending in claims for the quarterly $300.00 payments, the LOA is not required to be attached to the D8670 claim You are encouraged to enter your claims on the Secure Web Portal for faster and more accurate payments
QUESTIONS ON BILLING?
CRITERIA UPDATES • Impacted Anterior Teeth- Teeth that are impacted have been added as a qualifying criteria and will be evaluated and approved based on necessity. • Deep Impinging Overbite and Anterior Crossbite- These conditions will only be considered qualifying criteria if the teeth are causing tissue laceration and/or loss of gingival attachment. There MUST be photographic documentation and/or a detailed narrative of the laceration or loss of attachment. NOTE: These conditions have been approved in the past with only palatal irritations, inflammation, and/or indentations. In order to consistently meet the set criteria of this program, these can not be approved without sufficient documentation of destruction. • Severe Traumatic Deviation- Traumatic deviations are, for example, loss of a premaxilla segment by burns or by accident; the result of osteomyelitis; or other gross pathology. *Congenitally missing teeth are not considered a Severe Traumatic Deviation. Missing teeth should be indicated on Part 2 of the new request form. *A narrative should be written on Part 2 of the new request form explaining what the deviation is.
REQUEST FOR TREATMENT FORM
Please fill in each blank. Please check which type of treatment is being requested at this time. If Yes is checked for surgery, an explanation should be given as to what type and an estimated time frame during treatment.
Please fill in all boxes that apply Please indicate the location of each missing, impacted, or ectopic tooth If Severe Traumatic Deviation is checked off in section 4 of the scoring sheet, there MUST be an explanation of what the deviation is here in section 2.
Oral hygiene will be evaluated by the State on each case. If the client appears to have fair/poor hygiene, a hold may be placed on the client. Please give your impressions of the child’s hygiene here. Please list any restorative treatment needs, including tooth replacement needs, if necessary
Please complete the HLD index. An X should only be placed on the index for Deep Impinging Overbite or Anterior Crossbite if you are indicating tissue laceration or attachment loss is present. **NOTE: If you would like to indicate that the client has a Deep Overbite or an Anterior Crossbite but there is no tissue destruction present, you may state that in your narrative below for consideration.
This section has been created to allow you to give any explanation that will substantiate your request for approval. Please describe any reasons you feel this case is medically necessary to receive treatment.
REQUEST FORM QUESTIONS?
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