Texas Provider Best Practices
2013 – Medicaid and CHIP
Agenda

Understanding the Office Reference Manual (ORM)

Most Common Denial Reasons and Codes

Definition of Medical Necessity

Clinical Criteria

CHIP – Exceeding $564 Benefit Max

Narratives

X-rays / Photos

Appeals Process

Questions
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Office Reference Manual (ORM)…
The Office Reference Manual (ORM) is located on the
portal and on www.dentaquesttexas.com under
Provider Information.
Let’s take a tour!
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Most Common Denial Reasons…
Clinical
1. CHIP – No narrative or supporting documentation for exceeding
the $564 maximum.
2. Extractions – Submitting for a higher code than documentation
supports. For example, D7240 for a soft tissue impaction
3. Crown – Tooth does not have extensive decay on multiple
surfaces or moderate cuspal involvement.
4. Crown – No pre-op radiograph provided. Pre-op and post-op
radiographs are required.
5. Third molar extractions – Provider does not submit a tooth specific
narrative, the notes are generic or a template used for every prior
auth.
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Denial Reasons (cont’d)…
Administrative
1.Service exceeds benefit limitations or maximum benefit allowance.
2. Submitting provider is not the member’s Primary Care Dentist.
3. This procedure is a duplicate of a service previously processed.
4. Patient is not eligible for program.
5. This procedure has been submitted after the timely filing limit.
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Medical Necessity…
Medically necessary is defined in
the Texas Administrative Code
(TAC) Rule 353.2
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Pre-payment Review vs. Prior
Authorization
Covered dental services that indicate “Yes” in the “Review Required”
column will be subject to retrospective pre-payment review. These
procedures can be rendered before determination of medical necessity but
require submission of proper documentation (as indicated in the
“Documentation Required” column) with the claim form that supports
medical necessity.
As an option, services that indicate “Yes” in the “Review Required” column
can also be submitted for prior authorization prior to rendering the
services.
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Clinical Criteria
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Dental Extractions…
Documentation needed for pre - payment review or
prior authorization:
 Appropriate radiographs showing clearly the adjacent and
opposing teeth should be submitted for authorization review:
periapicals or panorex.
 Treatment rendered under emergency conditions, when
authorization is not possible, will still require that appropriate
radiographs showing clearly the adjacent and opposing teeth be
submitted with the claim for review for payment.

Narrative demonstrating medical necessity.
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Criteria…
 The prophylactic removal of asymptomatic teeth (i.e.
third molars) or teeth exhibiting no overt clinical
pathology is subject to consultant review.
 The removal of primary teeth whose exfoliation is
imminent does not meet criteria.
 Alveoloplasty (code D7310) in conjunction with four
or more extractions in the same quadrant will be
covered subject to consultant review.
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Endodontic…
Documentation needed for pre-payment review or prior
authorization:
Sufficient and appropriate radiographs showing clearly the adjacent and
opposing teeth and a pre-operative radiograph of the tooth to be treated;
periapicals or panorex. A dated post-operative radiograph must be
submitted for review for payment.
Treatment rendered under emergency conditions, when authorization is
not possible, will still require that appropriate radiographs clearly show:
The adjacent and opposing teeth.
Pre-operative radiograph and dated post-operative radiograph of the
tooth treated.
In cases where pathology is not apparent, a written narrative justifying
treatment is required.
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Criteria…
Root canal therapy is performed in order to maintain teeth that
have been damaged through trauma or carious exposure. Root
canal therapy must meet the following criteria:
Fill should be sufficiently close to the anatomical apex to ensure
that an apical seal is achieved.
 Fill must be properly condensed/obturated. Filling material does
not extend excessively beyond the apex.
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Authorizations for Root Canal therapy will not
meet criteria if:

Gross periapical or periodontal pathosis is demonstrated
radiographically (caries subcrestal or to the furcation, deeming the
tooth non-restorable).

The general oral condition does not justify root canal therapy due to
loss of arch integrity.

Root canal therapy is for third molars, unless they are an abutment for
a partial denture.

Tooth does not demonstrate 50% bone support.

Root canal therapy is in anticipation of placement of an overdenture.

A filling material not accepted by the Federal Food and Drug
Administration (e.g.Sargenti filling material) is used.
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Other Considerations…
 Root canal therapy for permanent teeth includes diagnosis,
extirpation of the pulp, shaping and enlarging the canals,
temporary fillings, filling and obturation of root canal(s), and
progress radiographs, including a root canal fill radiograph.
 In cases where the root canal filling does not meet
DentaQuest’s treatment standards, DentaQuest can require the
procedure to be redone at no additional cost. Any
reimbursement already made for an inadequate service may be
recouped after DentaQuest reviews the circumstances.
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Stainless Steel Crowns…
Documentation needed for pre-payment review or
prior authorization:
Appropriate radiographs showing clearly the adjacent and opposing teeth
should be submitted for authorization review: bitewings, periapicals or
panorex.
Treatment rendered under emergency conditions, when authorization is
not possible, will still require that appropriate radiographs showing clearly
the adjacent and opposing teeth be submitted with the claim for review for
payment.
Narrative demonstrating medical necessity if radiographs are not
available.
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Criteria…

In general, criteria for stainless steel crowns will be met only for teeth needing
multi-surface restorations where amalgams and other materials have a poor
prognosis.

Permanent molar teeth must have pathologic destruction to the tooth by caries
or trauma, and should involve four or more surfaces and two or more cusps.

Permanent bicuspid teeth must have pathologic destruction to the tooth by
caries or trauma, and should involve three or more surfaces and at least one
cusp.

Permanent anterior teeth must have pathologic destruction to the tooth by caries
or trauma, and should involve four or more surfaces and at least 50% of the
incisal edge.

Primary molars must have pathologic destruction to the tooth by caries or
trauma, and should involve two or more surfaces or substantial occlusal decay
resulting in an enamel shell.
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A request for a crown following root canal
therapy must meet the following criteria:
 Request should include a dated post-endodontic periapical
radiograph.
 Tooth should be filled sufficiently close to the radiological apex
to ensure that an apical seal is achieved.
 The filling must be properly condensed/obturated. Filling
material does not extend excessively beyond the apex.
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To meet criteria, a crown must be opposed by a
tooth or denture in the opposite arch or be an
abutment for a partial denture…
 The patient must be free from active and advanced
periodontal disease.
 The fee for crowns includes the temporary crown that
is placed on the prepared tooth and worn while the
permanent crown is being fabricated for permanent
anterior teeth. Payment for crowns must be billed on
seat date and not prep date.
 Cast Crowns on permanent teeth are expected to
last, at a minimum, five (5) years.
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Authorizations for Crowns will not meet
criteria if:
 A lesser means of restoration is possible.
 Tooth has subosseous and/or furcation caries.
 Tooth has advanced periodontal disease.
 Tooth is a primary tooth.
 Crowns are being planned to alter vertical dimension.
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Periodontal Treatment
Documentation needed for pre-payment review or
prior authorization:
Radiographs – periapicals or bitewings preferred.
Complete periodontal charting with AAP Case Type.
Treatment plan.
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Criteria…
 A minimum of four (4) teeth affected in the quadrant.
 Periodontal charting indicating abnormal pocket
depths in multiple sites.
 Additionally, at least one of the following must be
present:
1. Radiographic evidence of root surface calculus.
2. Radiographic evidence of moderate to severe loss
of bone support.
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CHIP…
Covered Dental Services are subject to a $564 annual benefit limit unless
an exception applies.
CHIP Members who have exhausted the $564 annual benefit limit continue to
receive the following Covered Dental Services in excess of $564 annual benefit
maximum:
(1) The preventive services due under the 2009 American Academy of Pediatric
Dentistry Periodicity schedule (Volume 32, Issue Number 6 at pp. 93-100);
and
(2) Other Medically Necessary Covered Dental Services approved by the Dental
Contractor through a prior authorization process. These services must be
necessary to allow a CHIP Member to return to normal, pain and infection-free oral
functioning. Documentation to support medical necessity must be submitted with the
prior authorization. This includes narrative, x-rays and/or photos when x-rays are not
possible.
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CHIP – Medically Necessary
Services…
Typically this includes:
- Services related to the relief of significant pain or to
eliminate acute infection.
- Services related to treat traumatic clinical conditions.
- Services that allow the CHIP Member to attain the basic
human functions (e.g. eating, speech, etc.).
- Services that prevent a condition from seriously
jeopardizing the CHIP Member’s health/functioning or
deteriorating in an imminent timeframe to a more serious
and costly dental problem.
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Narratives…
Narratives are very important to our Dental Director when making clinical decisions.
Many of you have asked the questions, “What is a good narrative?” Every member
is unique and a narrative should be submitted to address the member. This means
that submitting the same narrative verbatim for multiple members would not be
acceptable. While we cannot provide you with specific narratives, we can provide
some helpful tips.
A good narrative:
The narrative should be tooth specific and describe the symptoms that are being
exhibited by the member.
If the member is or has been on antibiotics, this should be included in the narrative.
If the member is or has been on painkillers for an extended period of time, this
should be included in the narrative.
If the member’s age could be a determining factor, this should be included in the
narrative.
If there is any symptom present that is not identifiable by viewing the x-ray, this
should be included in the narrative (such as inflammation or pain beyond normal
eruption).
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Narrative (cont’d)…
A bad narrative:
 Does not describe a condition that meets clinical criteria for
approval. The example below does not provide enough
information to deem teeth as symptomatic.

Impacted 1,16,17,32. Request Removal due to pain
 A template or blanket statement that is used for every member.
 Recommending extraction for solely preventive reasons.
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X-Rays
We require that x-rays be mounted
Claims received with more than four (4) un-mounted x-rays will be returned
for mounting.
Please make sure the x-rays are of diagnostic quality, properly mounted,
dated, marked with left and right, and identified with the member's name.
Below are the options in which you can submit x-rays to us. These are (in
order of preference):
1. Electronically using either NEA (National Electronic
Attachment) or the DentaQuest Provider Web Portal.
2. Mail duplicate x-rays with your ADA form.
3. Send original x-rays, your ADA form, and a self-addressed
stamped envelope (SASE) so that we may return the x-rays to
you.
We are unable to return x-rays received without a SASE. X-rays without a
SASE will be scanned and recycled.
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Appeals…
You have 120 days from the date of the EOB to submit an appeal. To
submit an appeal, make a copy of the EOB and circle the claims in
question. Please note why you are requesting the appeal and provide
documentation such as a narrative, photos and X-rays to support medical
necessity.
If you don’t have the EOB, you can submit the appeal using your office’s
letterhead. Please include the following information:
Claim number
Member name, date of birth and member ID
Dentist name, NPI and TPI
Explanation for the appeal
Documentation such as a narrative, photos and X-rays to support medical
necessity. In addition, if your office uses NEA, you may submit the NEA
number.
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Appeals (cont’d)…
Appeals may be submitted by mail to the following address:
DentaQuest-TX HHSC Dental Services
Complaints & Grievances
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759
If the appeal is denied, a peer-to-peer can be requested by
contacting the call center at 1-800-896-2374.
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Appeals (cont’d)…
Appeals may also be submitted on the portal using the following
steps:
Log onto the portal and click on Tools
Then, click on Contact DentaQuest
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Appeals (cont’d)…
You will be taken to a Message screen where you will be able to submit
information electronically (screenshot on next slide).
You can only submit 1 attachment using this process so it is important that
you do the following to keep the process as simple as possible. Please
make sure the following is provided:
Claim number (search function)
Member name, date of birth and member ID (search function or
description box)
Dentist name, NPI and TPI (search function or description box)
Explanation for the appeal
NEA number for x-rays (if available)
If the x-rays are not available via NEA, they can be uploaded as
an attachment. If you have multiple attachments, you must zip the
file prior to uploading to comply with the 1 attachment rule.
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Please remember that it is not necessary to submit a copy of the ADA claim form
and the EOB if all information regarding the claim is documented in the Description
box or search fields and no changes are being made to the original ADA claim form.
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www.dentaquesttexas.com...
Quick access to provider resources:

Training Schedules and presentations – Provider Information /
Training Schedule

Office Reference Manual (ORM), Ortho Policy, Interim Care
Transfer From – Provider Information / Important Documents

Provider Newsletters (Texas Roundup) – Provider Information /
Provider Newsletters
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Portal Overview
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Enter your Username and Password to access the Dentist Home Page
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Claims/Pre-Authorization Menu
The Claims/Pre Authorization
menu includes the following menu
items:
•
Claim/Pre-Authorization Status Search- Use this sub-menu item to search for
the status of a claim or pre-authorization.
•
Remittance Advice Search- Use this sub-menu item to view remittance advice
statements.
•
Dental Claim Entry – Use this sub-menu to enter and submit dental claims.
•
Dental Pre-Authorization Entry- Use this sub-menu to enter and submit dental
pre-authorizations.
•
Dental Claim Confirmation Report- Use this sub-menu to create a dental
claims confirmation report. This report will list all claims that have been
submitted through the web for that day.
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Dental Claim Entry
1
2
3
4
5
Key
1.
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.
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.
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Dental Pre-Auth Entry
1
2
3
4
5
Key
1.
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.
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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.
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Claim/Pre-Authorization Status List
This page appears with any claims or pre-authorizations that met your criteria search
•
•
•
•
•
•
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.
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Questions and Answers
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