Medicaid Dental Program Overview for Hygienists

Presenter:

Dianne Baum – Dental Program AdministratorContact Information: (360) 725-1590 or e-mail at dianne.baum@hca.wa.gov

1

Program Management The Dental Program is part of the Healthcare Benefit

Utilization Management Section in the Division of Healthcare Services

Staffing:• Gail Kreiger, RN, Section Manager• Dianne Baum, Dental Program Administrator• Contracted Consultants – 2 Dentists & 3 Orthodontists

Dianne Baum has worked for DSHS/HCA for 31+ years: • Manages the Dental Program since 2011 • 25+ years experience in Authorization• 6 years with design and development of Provider One

2

Covered Services

3

The agency pays licensed providers participating in the Agency’s Dental-Related Services Program for only those services that are within their scope of practice (WAC 182-535-1070(2)).

Coverage Decisions

4

Adult Dental is an optional benefit and can be eliminated or limited by Legislature:• Dental services are controlled by the budget, state

rules and regulations, and CMS• Fees can only be updated by legislation• WAC 182-501-055 is used to make determinations on

new services• WAC 182-535 - Dental Coverage• WAC 182-502 - Provider Requirements• WAC 182-502-0160 – Billing the Client

WACs can be obtained at this link: http://app.leg.wa.gov/wac/default.aspx?Cite=182

Tobacco Counseling

5

Information about Tobacco Counseling is found in the Physician-Related Services Billing Guide starting on page 42:

Payment for a smoking cessation referral: the agency will pay a provider which may include Physicians, Advanced Registered Nurse Practitioners (ARNPs), Physician Assistants (PAs), Dentists, and Dental Hygienists for a smoking cessation referral (T1016) when all of the following are met:

• The client is pregnant or 18 years of age and older;• The client presents a Services Card and is covered by a Benefit Services Package (BSP);• The client is NOT eligible for the AEM program or enrolled in the Family Planning Only or Take

Charge program;• The referral is billed with ICD-9 diagnosis of 305.1, 649.03, or 649.04;• The client is evaluated in person, for the sole purpose of counseling the client to encourage

them to call and enroll in the Smoking Cessation Program;• This service may be provided in combination with another service or evaluation and

management office visit that is within the provider’s scope of practice.

http://www.hca.wa.gov/medicaid/billing/Documents/physicianguides/physician-related_services_mpg.pdf

Facts and Statistics

6

Services for adults only 21+• FQHC visits = 300,687• FQHC clients = 102,075• Hygienist Visits = 1,884• Hygienist Clients = 1,237

All other Dental

• Visits = 298,029• Clients = 118,652

In 2014, there were 214 Individual Hygienists registered in ProviderOne and 23 of those billed Apple Health for a total of 69,465 claims.

      

* Exactly 50% of adult visits are FQHCs.

Facts and Statistics

7

Authorizations:• In 2014 we received an average of 3,500

dental authorization requests per month.• Current estimated time for an authorization

decision is 30 – 35 days.• Prior authorization is required for certain

services and for limitation extensions.

      

Services Covered for Independent Hygienists

8

Limited Visual Oral Assessment

9

CDT Code Description PA?Maximum

Allowable Fee

D0190 Screening of a Patient N

20 and under $10.20

21 and over $10

D0191 Assessment of a Patient N

20 and under $10.20

21 and over $10

The Agency covers limited visual oral assessments or screenings, up to two per client, per year, per provider only when the assessment or screening is:• Performed by a licensed dentist or dental hygienist to determine the need

for sealants, fluoride treatment, and/or when triage services are provided in settings other than dental offices or dental clinics (e.g., alternative living facilities, etc.)

• Not performed in conjunction with other clinical oral evaluation services• Provided by a licensed dentist or licensed dental hygienist• Only one screening or assessment covered per client per visit

Dental Prophylaxis

10

The Agency covers prophylaxis as follows: • Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains when

performed on primary or permanent dentition. Limited to once every:

• 6 months for a client 18 years of age and younger• 12 months for a client from 19 years of age and older• 4 months for a client residing in a skilled nursing home or clients of the Developmental Disability

Administration Is reimbursed only when the service is performed:

• At least 6 months after periodontal scaling and root planing, or periodontal maintenance services, for clients from 13 to 18 years of age, clients residing in a skilled nursing home or client of the Developmental Disability Administration

• At least 12 months after periodontal scaling and root planing, or periodontal maintenance services, for clients from 19 years of age and older

• Is not reimbursed separately when performed on the same date of service as periodontal scaling and root planing, periodontal maintenance, gingivectomy, or gingivoplasty

CDT Code Description PA? Age LimitationMaximum

Allowable Fee

D1110 Prophylaxis – Adult NClients 14 years of age and older only

20 and younger $36.25

21 and over $34.38

D1120 Prophylaxis – Child NClients through age

13 only$22.98

Topical Fluoride Treatment

11

The Agency covers:• Fluoride rinse, foam or gel, including disposable trays, per

provider or clinic as follows: Clients 6 years of age and younger or receiving orthodontic treatment or residing in an Alternate

Living Facility (ALF) or covered by DDA: Up to 3 times within a 12 month period. Clients age 7 to 18 years of age: Up to 2 times within a 12 month period Clients age 19 and older: Once within a 12 month period

CDT Code Description PA? Age RequirementMaximum

Allowable Fee

D1206 Topical fluoride varnish

N See above

20 and younger $13.25

21 and older $12.32

D1208Topical Application

of FluorideN See above

20 and younger $13.25

21 and older $12.32

Note: CDT codes D1206 and D1208 are not allowed on the same day. The fluoride limit per provider, per client, for CDT codes D1206 and D1208 is the combined total of the two - not per code. The codes are considered equivalent, and a total of 3 or 2 fluorides are allowed, not 3 or 2 of each. The ABCD rate is $23.41 for clients age 5 and under and only payable to dentists.

* Additional topical fluoride applications only on a case-by-case basis and when prior authorized.

Oral Hygiene Instruction  The agency covers oral hygiene instruction only for clients who are 8 years

of age and younger. Individualized oral hygiene instruction for home care includes tooth brushing techniques, flossing, and use of oral hygiene aids.

Oral hygiene instruction is covered: • No more than once every 6 months, up to 2 times within a 12 month period• Only when not performed on the same date of service as prophylaxis

12

CDT Code Description PA? Age LimitationMaximum

Allowable Fee

D1330 Oral Hygiene Instructions NClients 8 years of age and younger

only$12.97

Note: The Agency covers oral hygiene instruction only when provided by a licensed dentist or a licensed dental hygienist and the instruction is provided in a setting other than a dental office or clinic.

Nonsurgical Periodontal Services Covers periodontal scaling and root planing for the number of teeth scaled that are

periodontically involved once per quadrant: • For clients 13 to 18 years of age, per client in a two-year period on a case-by-case basis, when

prior authorized.• For clients ages 19 years of age and older without prior authorization, and only when:

The client has X-ray evidence of periodontal disease. The client's record includes supporting documentation for the medical necessity of the

service, including complete periodontal charting and a definitive diagnosis of periodontal disease.

The client's clinical condition meets current published periodontal guidelines. Performed at least two years from the date of completion of periodontal scaling and

root planing or surgical periodontal treatment, or at least 12 calendar months from the completion of periodontal maintenance.

Considers ultrasonic scaling, gross scaling, or gross debridement to be included in the procedure and not a substitution for periodontal scaling and root planing.

Covers periodontal scaling and root planing only when the services are not performed on the same date of service as prophylaxis, periodontal maintenance, gingivectomy, or gingivoplasty.

See below for clients covered by DDA and who reside in a skilling nursing home.

13

Adjust / Void a Claim

14

CDT Code Description PA? RequirementsAge

LimitationsMaximum

Allowable Fee

D4341Periodontal Scaling and Root Planing – four or

more teeth per quadrantY

Quadrant designation required

Clients 13 to 18 years of age only.

$25.49

D4341Periodontal Scaling and Root Planing – four or

more teeth per quadrantN

Quadrant designation required

Clients 19 years of age

and older only.

19 – 20 $25.49

21 and older $24.18

D4342Periodontal Scaling and Root Planing – one to

three teeth per quadrantY

Quadrant designation required

Clients 13 to 18 years of age only.

$25.49

D4342Periodontal Scaling and Root Planing – one to

three teeth per quadrantN

Quadrant designation required

Clients 19 years of age

and older only.

19 – 20 $25.49

21 and older $24.18

Nonsurgical Periodontal Services

Periodontal Maintenance

 

Covers periodontal maintenance for clients from 13 to 18 years of age, once per client in a 12-month period on a case-by-case basis, when prior authorized and clients 19 years of age and older without prior authorization and only when:

• The client has X-ray evidence of periodontal disease. • The client's record includes supporting documentation for the medical necessity, including complete periodontal charting with

location of the gingival margin and clinical attachment loss and a definitive diagnosis of periodontal disease. • The client's clinical condition meets current published periodontal guidelines. • The client has had periodontal scaling and root planing but not within 12 months of the date of completion of periodontal

scaling and root planing, or surgical periodontal treatment. • The client's clinical condition meets current published periodontal guidelines.

Covers periodontal maintenance for clients residing in a skilled nursing home or covered by DDA:

• Periodontal maintenance (four quadrants) substitutes for an eligible periodontal scaling or root planing, twice in a 12-month period.

• Periodontal maintenance 6 months after scaling or root planing.

15

CDT Code Description PA? Age LimitationsMaximum

Allowable Fee

D4910 Periodontal Maintenance YClients 13 to 18 years

of age only$49.47

D4910 Periodontal Maintenance NClients 19 years of age and older only

18-20 $46.00

21 and over $49.47

Note: A maximum of 2 procedures of any combination of prophylaxis, periodontal scaling and root planing, or periodontal maintenance are allowed in a 12 month period.

Billing a Client

16

Billing a Client Billing a Client, allowing providers, in limited circumstances, to bill fee-for-

service or managed care clients for covered healthcare services, and allowing fee-for-service or managed care clients the option to self-pay for covered healthcare services. WAC 388-502-0160

17

18

19

20

21

Form 13-879

Online Services

22

23

Online Services Provider’s One-Stop Shopping Website

http://www.hca.wa.gov/medicaid/Provider/Pages/index.aspx

24

Online Services Provider’s One-Stop Shopping Website

(cont’d) Webinars with each hyperlink

25

Online Services Provider’s One-Stop Shopping Website

(cont’d) Links Tab

Easy to find direct links to Medicaid

Programs

26

Online ServicesProviderOne Billing and

Resource Guide• Link noted below

http://www.hca.wa.gov/medicaid/provider/Documents/provideroneguide/providerone_billing_and_resource_guide.pdf

Contact Us

27

48 hr turnaround for Service Limits checksBe sure to include the Date of Service (DOS)Procedure Code and the date range for searchProviderOne Domain number

Must include timeframe in comments

28

Online Services Helpful links related to client eligibility

For the following fact sheets, use the hyperlink listed below• Client Services Card Fact Sheet• Client Eligibility Verification Fact Sheet• Interactive Voice Response Fact Sheet• Magnetic Card Reader Fact Sheethttp://www.hca.wa.gov/medicaid/provider/pages/factsheets.aspx

E-Learning webinar on how to check eligibility in ProviderOne http://www.hca.wa.gov/medicaid/provider/Pages/webinar.aspx • Instructions available in Program Update memo dated

May 31, 2012

Self-paced online tutorial on how to check Medicaid eligibility http://www.hca.wa.gov/medicaid/ProviderOne/pages/phase1/tutorials.aspx

29

Online Services See the Provider Training website for links to recorded

Webinars, E-Learning, and Manuals http://www.hca.wa.gov/medicaid/provider/pages/training.aspx

Provider Enrollment website http://www.hca.wa.gov/medicaid/provider/pages/newprovider.aspx

Billing Questionsproviderrelations@hca.wa.gov

Dental Resources: Find the Dental Medicaid Provider Guide (formerly the billing

instructions) at http://www.hca.wa.gov/medicaid/billing/pages/dental-related_services.aspx

Dental Web Pagehttp://www.hca.wa.gov/medicaid/dentalproviders/Pages/dental.aspx

Emergency Oral Health Factsheet http://www.hca.wa.gov/medicaid/dentalproviders/Pages/index.aspx

Authorization Web pagehttp://www.hca.wa.gov/medicaid/authorization/Pages/index.aspx

Client Benefit Limit Inquiry:http://www.hca.wa.gov/medicaid/provider/documents/clientbenefitlimitinquiry2014.pdf 30

Online Services

AuthorizationsAuthorizations

31

AuthorizationsAuthorizations

32

AuthorizationsAuthorizations Complete Authorization Form

13-835

a) To begin the authorization process providers need to complete HCA Form 13-835. ProviderOne can begin processing the authorization request once the Agency receives this form filled out correctly.

b) Access the online authorization form 13-835 at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx

33

Step by step instructions:

ProviderOne Billing and Resource Guide

Directions for Authorization form Directions for Authorization form 13-83513-835

34

Directions for Authorization form 13-Directions for Authorization form 13-835835

35

Directions for Authorization form Directions for Authorization form 13-83513-835

36

Example Authorization 13-835Example Authorization 13-8351. Example of a completed

Authorization Form 13-835a) Fill (type) in all required

fields as indicated on the directions page.

b) Use the codes listed in the directions for the required fields.

c) Add as much other detail as necessary that may help in approval.

d) The data on this form is scanned directly into ProviderOne.

e) Processing begins as soon as a correctly filled out form is received.

37

Step by step instructions:

ProviderOne Billing and Resource Guide

AuthorizationsAuthorizations

2. Submit Authorization Request to the Agency with Required Back-upa) By Fax

– 1-866-668-1214– Form 13-835 must be first

b) By MailAuthorization Services OfficePO Box 45535Olympia, WA 98504-5535

38

Another option for submitting photos or x-rays:

Providers can submit dental photos or x-rays for Prior Authorization by using the FastLook and FastAttach services provided by National Electronic Attachment, Inc. (NEA). Providers may register with NEA by visiting www.nea-fast.com and entering “FastWDSHS” in the promotion code box. Contact NEA at 800-782-5150 ext. 2 with any questions. When this option is chosen, fax requests to the Agency and indicate the NEA# in the NEA field on the PA Request Form. There is an associated cost, which will be explained by the NEA services.

If mailing x-rays, photos, CDs, or other non-scannable items, do the following:Place the items in a large envelope; Attach the PA request form to the outside of the envelope;Write on the outside of the envelope:

• Client name • Client ProviderOne ID • Your NPI • Your name • Sections the request is for:

Dental or Orthodontic

Check Status of an Authorization RequestCheck Status of an Authorization Request

39

Check Status of an Authorization Check Status of an Authorization RequestRequest

Select Provider Authorization Inquiry from the provider home page.

40

Search by one of the Options: Prior Authorization

number; or Provider NPI and Client ID;

or Provider NPI, Client Last &

First Name, and the client birth date.

The system may return the following status information:

41

Check the Status of a RequestCheck the Status of a Request

The above example authorization

request (number) is in approved status.

Other possible status of the authorization

request is listed in the table at the left.

42

Cover Sheets are located at : http://www.hca.wa.gov/medicaid/billing/pages/document_submission_cover_sheets.aspx

Submit Prior Authorization RequestSubmit Prior Authorization Request

43

Questions?