SCPHCA Dental Provider Updates
Agenda
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Introduction
Latest News
Web Portal Navigation
Related Documents
Claim Completion Reminders
Prior Authorization Reminders
Coordination of Benefits
Questions
*Helpful Hints*
are identified throughout the presentation
Introductions
DentaQuest
Tycie Sellers, Provider Relations Representative
Latest News
 Express Lane Eligibility Initiative
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Adding approximately 70,000 new beneficiaries
Children are already eligible, but were not enrolled
Automatic enrollment by SCDHHS
Dental Providers may encounter new patients
Utilization by new beneficiaries being monitored
 Foster Care Initiative
 SCDHHS and SCDSS collaborating to ensure care
coordination for foster children
 No impact to provision of dental services
Reminder of Adult Coverage
Limitations
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Treating Adults
 dental services may be reimbursable when performed in preparation for or during
the course of treatment of one of the established medical conditions outlined in the
Dental ORM:
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Organ transplants
Chemotherapy
Radiation of head and/or neck for cancer treatments
Total joint replacement
Heart valve replacement
Treatment of trauma related injuries in a hospital/outpatient setting
 Effective January 1, 2012, medical services (covered oral surgical procedures)
may be billed by oral surgeons
 Covered CPT procedures only
 Rendered to members age 21 and older in emergency situations
 Include required documentation and indication of emergency on claim submission:
 CMS 1500 Form: check field 24C
 Web submission: including the word “emergency” in the remarks field
 Utilization will be monitored by DentaQuest and SCDHHS Program Integrity
Insure Kids Now Outreach
Federal initiative connecting kids
to coverage
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Part of the Children’s Health Insurance
Program (CHIP) Renewal Act of 2009
Mandates state Medicaid agencies to
supply quarterly provider directories that
reflect up-to-date data on office locations
and more detailed information on office
hours, languages spoken, and special
capabilities
www.insurekidsnow.gov
If your office has not supplied this
form back to DentaQuest, please do
so as soon as possible!
Additional copies available on Provider
Web Portal and from Customer Service
DentaQuest Provider Web Portal
https://govservices.dentaquest.com/
Enter your Username and Password to access the Dentist Home Page
Dentist Home Page
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1. Portal Menus
2. Welcome-This section contains
the DentaQuest welcome
message.
3. Plan Messages-Contains any
plan messages from
DentaQuest.
4. Health News-Contains
information and news articles
of interest.
5. My HealthTools/Resourcescontains links to various
health resources.
6. Contact-Contains DentaQuest’s
contact information.
7. Message Center-Contains
messages sent to you from
DentaQuest. (appears if you
have messages in your
Inbox.)
8. FAQ-This link opens to view
frequently asked questions.
9. Event Calendar-This link opens
the Event Calendar.
10. Related Documents-This link
opens the Document List
page.
*Helpful Hint*
“Related Documents”
contains helpful
resources such as:
 Current ORM
 Fee Schedules
 SCDHHS Provider
Bulletins
 Appeal Form
Dental Office Reference Manual
The most current version is
always available through the
provider web portal.
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Important contact information
Review of SCDHHS policy
Explanation of procedures
Claim filing options
Prior Authorization
Requirements and Processes
Benefits and Limitations
Recommended clinical criteria
Dental Office Reference Manual
 To review covered benefits, refer to
 Exhibit A for Children
 Exhibit B for Adults
 Exhibit C for coverage within the Mental Retardation and Related
Disabilities (MR/RD) Waiver Program.
 Benefits are listed by
 Code
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Brief Description of the Benefit
Age Limitations
Teeth Covered
Review Requirements
Benefit Limitations
Documentation Requirements
January 1, 2012 Release of the ORM
Updated Format to Benefit Tables
OLD FORMAT
Code
Description
D2940 Sedative Filling
Age
Limitation
0-20
Teeth Covered
Teeth 1 through
32, A through T
Review
Required
No
Benefit Limitations
Documentation Required
Not allowed with D2000 or
D3000 series codes. Limit of
one per 36 months per tooth.
NEW FORMAT
Code
Description
D2940 Protective Restoration
Age
Limitation
Teeth Covered
Review
Required
0-20
Teeth 1-32, A-T
No
Benefit Limitations
One of (D2140, D2150, D2160,
D2161, D2330, D2331, D2332,
D2335, D2391, D2392, D2393,
D2394, D2930, D2931, D2932,
D2934, D2950, D2951, D2954,
D3220, D3310, D3320, D3330)
per 1 Day(s) Per Patient. One of
(D2940) Per 36 month(s) Per
Patient. Not allowed with
D2000 or D3000 series codes on
the same date of service.
Documentation Required
CDT Fee Schedule
Proc
Payment Rate prior
to 04/08/2011
Payment Rate 3%
reduction
effective
04/08/2011
Payment Rate
3%
reduction
effective
07/11/2011
D0120
$23.40
$22.70
$22.00
D0140
$38.34
$37.19
$36.04
D0145
$23.40
$22.70
$22.00
D0150
$40.94
$39.71
$38.48
D0210
$53.29
$51.69
$50.09
D0220
$13.65
$13.24
$12.83
D0230
$11.05
$10.72
$10.39
D0240
$20.15
$19.55
$18.94
D0270
$13.00
$12.61
$12.22
D0272
$20.15
$19.55
$18.94
D0330
$53.29
$51.69
$50.09
D1110
$43.54
$42.23
$40.93
CPT Fee Schedule
Proc
Payment Rate prior to
04/08/2011
Payment Rate 3%
reduction
effective
04/08/2011
Payment Rate 3%
reduction
effective
07/11/2011
13132
$415.05
$402.60
$390.15
20670
$275.97
$267.69
$259.41
20680
$423.15
$410.46
$397.76
20900
$297.43
$288.51
$279.58
20902
$265.42
$257.46
$249.49
21025
$636.61
$617.51
$598.41
21026
$420.13
$407.53
$394.92
21029
$537.29
$521.17
$505.05
21030
$351.66
$341.11
$330.56
21031
$269.34
$261.26
$253.18
21032
$272.91
$264.72
$256.54
21034
$966.92
$937.91
$908.90
Appeal Form
DentaQuest Provider Appeal Form
DentaQuest Attn: Complaints & Grievances 12121 N. Corporate Pkwy. Mequon, WI 53092
Member Name: _________________________________________________
Member Identification Number: ___________________________________
Date of Service: _________________________________________________
Date EOB was received: __________________________________________
Authorization Number: __________________________________________
Date Authorization was received: __________________________________
-----------------------------------------------------------------------------------------------Provider Name: _________________________________________________
Location Number: _______________________________________________
Office Contact: __________________________________________________
Office Phone Number: ____________________________________________
-----------------------------------------------------------------------------------------------Reason for Appeal:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Outcome office is requesting:
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________
Patient Menu
Member Eligibility Search
Performing a Member
Eligibility Search
Click Member Eligibility
Search in the Patient menu
to display the Member
Eligibility Search page.
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Select the provider from the Select a Location and Provider drop-down list.
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Type in the Service Date.
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Type in the DOB (date of birth) in mm/dd/yyyy format or select it from the pop-up calendar in
the DOB field.
*This is a required field.
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You must enter a DOB and Member Number -OR- a DOB and Last Name and partial First
Name.
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To add additional rows click Add Member. (Able to search up to 30 members at one time)
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To delete a member from the search, click the Delete link at the end of the row.
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Click Search-the Member Eligibility List page will appear.
Member Eligibility List
•Active (Eligible): there is a match between the member's active coverage and the dentist's
active networks on the date of service.
•Ineligible (Not Eligible): the member is not active on the date of service.
•Not Found (Member Not Found): a matching member could not be identified.
•Click the Member Name link to display the Member Detail page
•Click Search Again to redisplay the Member Eligibility Search page and repeat the
search process
•Click Download File to download the search results
•Click on Printer Friendly Format to print the results
Member Detail Page
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To view benefit maximums (if applicable), click on View Benefit Maximums, the Benefit Maximum detail
screen will appear.
To view a list summary of claims for the specific member, click View Claims; the Claim Status List page
appears.
To view the member’s service history (available if they are eligible), click View Service History; the
Member Service History page appears.
To search for a dentist, click View Provider Directory; the Find a Dentist page appears pre-populated
with information for the dentist you selected in the eligibility check.
The Eligibility Information section lists the current Plan name.
The Other Coverage section lists cross-coverage information (COB) for the member.
Broken Appointment
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Click on Broken Appointment in the Patient menu to add a Broken Appointment
Enter Basic Information, Member Information and Appointment Details
Click on Submit
To enter another Broken Appointment click on Add a New Broken Appointment
Dental Claim Entry
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Key
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Basic Information-Service Date, Group NPI, Service Office, Treating Dentist and POS (Place of Service)
2.
Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency,
COB,EPSDT, Notes
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Member Eligibility-DOB, Member ID, Last Name, First Name
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Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt
5.
File Attachments- click Add File to upload an attachment
Dental Pre-Auth Entry
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Key
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Basic Information-Group NPI, Service Office, Treating Dentist and POS (Place of Service)
2.
Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency,
EPSDT, Notes
3.
Member Eligibility-DOB, Member ID, Last Name, First Name
4.
Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt
5.
File Attachments- click Add File to upload an attachment
Claim/Pre-Authorization Status Search
This page allows you to conduct a claim or pre-authorization
search.
**At least one search criteria must be entered to perform a search**
Search Criteria Key:
1. Member Last Name
2. Member First Name
3. Member Number
4. Member DOB
5. Servicing Dentist
6.Claim/Pre-authorization Number
7. Type: Dental Claim or PreAuthorization
8. Status Category: Successfully
Entered, Accepted, In Process,
Adjudicated, Finalized
9. Date From/To: Enter the Date of
Service
10. Claim Received Date From/To:
Enter the Claim or Pre-auth Received
Date.
Claim/Pre-Authorization Status List
This page appears with any claims or pre-authorizations that met your criteria search
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To download the list, click Download File
To view details on a claim/pre-authorization, click the Claim/Pre-Authorization Number link
To view the member’s details for a claim, click the Member Name link
To view the Dentist Directory Detail page, click the Dentist link for a claim
To perform a new search, click Search Again
To perform a remittance advice search, click RA Search
Claim Status Categories and Descriptions
The following table lists and describes the claim status categories for your
claims and pre-authorizations in the Portal.
Description
Definition
Successfully Entered
The claim/encounter has been successfully entered.
Accepted
The claim/encounter has been accepted into the claim adjudication
system.
In Process
The claim/encounter is being processed in the claim adjudication
system.
Adjudicated
The claim/encounter has been completed. Waiting to process
payment.
Finalized
The claim/encounter has completed processing and payment (or
approval for a pre-authorization). No more action will be taken.
Adding Billed Amount Lists
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1. On the Administration menu click on Billed Amount List.
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2. Click the Add Billed Amount List link.
3. In the Billed Amount List Name enter
the name you want the list to have.
4. In the Code field enter the first code
you are entering to the list.
5. In the Fee Amount field enter the fee for
the procedure code.
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6. Click the plus arrow to add a new code.
Repeat step 6 for each procedure code
you are adding to the list.
7. Once you have added all the procedure
codes and fee amounts, click Submit.
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Adding Billed Amount Lists cont.
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8. On the Billed Amount Detail page
that appears, click the Add Billed
Amount Association link.
9. In the Service Office field on the
Add Billed Amount List
Association page select the service
office you want to associate this list
with from the drop-down list.
10. Click the Add button to add the
association.
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The billed amount list and
association is now active for this
service office.
Tools Menu
Click the Tools menu to display the sub-menu items:
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User Profile- Use this sub-menu to view your user information and change your
name, password, and email address.
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Inbox- use this sub-menu to view and manage any messages sent to you
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Contact DentaQuest- use this sub-menu to send secure messages
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Find a Dentist - Use this menu item to search for a specific type of dentist, view
detailed provider information, and get directions to a dentist’s office.
Send Secure Messages
1.
Message Type-select from the
drop-down list: Location
Information Change, Provider
NPI Info, Provider Authorization,
Provider Claims, Remittance
Documents
2.
Attachment- To add an
attachment click on Upload.
You can have only one
attachment per message
3.
Claim/Pre-Authorization
Number -Click on Search to
search for a claim or preauthorization
4.
Dentist Name- Click on Search
to search for a Dentist Name
5.
Description-Type your
question, comment or
suggestion in the text box.
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More Helpful Hints
*Helpful Hints*
on Claim Submission
To ensure your dental claims are accepted please be sure to:
 Include the treating dentist signature in box #53. Acceptable
signatures include: “Signature on file”, electronic name and typed
names.
 Indicate in box #4 if the member has other insurance.
 Check the appropriate Place of Service in box #38.
 Remember to submit documentation along with the claim even
when the services have been prior authorized
 If you are supplying a voided claim, enter “void” or “adjustment” in
the remark field box #35 and include a SCDHHS Form 130 with
your submission.
*Helpful Hints*
on Claim Submission
 CDT claims must be submitted on a 2006 or newer ADA claim
form (found at www.ada.org).
 CPT claims must be supplied on a CMS 1500 claim form.
 Mailed claims or authorization requests should be submitted to
P.O. Box 2136
Columbia, SC 29202-2136
 Resubmit denied claims or service lines once. Multiple
resubmissions will result in unnecessary duplicates.
*Helpful Hints*
Submitting Authorization Requests
 Indicated Predetermination/Preauthorization on an approved claim
format.
 ADA Format: check Predetermination Box
 CMS 1500 Format: leave Date of Service blank
 Do NOT submit D9500
 Methods of submitting Auth Requests:
 Electronically through your clearinghouse or the DQ web portal
 Paper
 Emergency submissions are accepted through the DQ emergency
authorization fax line or email address
 See your Dental ORM for detailed instructions
*Helpful Hints*
on Providing Documentation:
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Narratives of Medical Necessity should be provided in the “Notes”
or “Remarks” field or included as an attachment.
 Include enough information to reflect the patient’s health situation
and why the elected services are medically necessary
 Be sure that the information is legible
 Patient chart notes can be helpful supplements to support medical
necessity
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X-rays should be mounted and of diagnostic quality.
 Consider scanning and supplying X-rays as attachments.
Electronic submission is also available through National Electronic
Attachment (NEA).
 Keep your originals on file
 If you’d like your X-rays returned, so indicate by including a selfaddressed stamped envelope (SASE).
*Helpful Hints*
Coordination of Benefits
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Indicate on the claim form if the member has other insurance
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Attach a copy of the primary’s EOB whenever possible –
especially if the primary policy has termed
 If you use NEA to do so, denote “COB information included” in the Remarks
field along with the attachment number
 If you upload the primary EOB through the web portal, be sure to check the
COB box
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If the patient only has medical primary insurance, there is no need
to file for COB with a dental claim
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Medicaid beneficiaries cannot be charged deductibles or
copayments under any active primary insurance policy
THANK YOU
for your time and attention today!
QUESTIONS?
Provider Web Portal (PWP)
www.dentaquest.com
Provider Customer Service and IVR
888.307.6553
Beneficiary Customer Service and IVR
888.307.6552