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Dental Services September 2020

Alaska Medicaid Provider Training

2

Overview

• Provider Enrollment

• Recipient Eligibility

• Covered Services

• Service Authorization

• TPL

• Billing

• Reimbursement

3

Provider Enrollment

4

Alaska Medical Assistance Provider Enrollment

• Individuals must meet the general participation requirements for Alaska Medicaid providers

• Individual dentists must have an active license to practice dentistry under AS 08.36

• Dentists who are practicing orthodontics must have an active certification from the

appropriate specialty board recognized under AS 08.36.246

• Dentist who will enroll as part of a dental group must first enroll individually

• Only licensed dentists may enroll as part of a dental group and must affiliate to the group

in Health Enterprise

• Providers affiliated with a dental group must bill their services under the group, except

when performing services outside the group as part of another practice or job

5

Update Provider Information Form

http://manuals.medicaidalaska.com/docs/dnld/Form_Update_Provider_Information.pdf

All forms with original signatures

should be mailed to:

P.O. Box 240808

Anchorage, AK 99524-0808

Providers may also choose to deliver

them to Conduent located at:

1835 S. Bragaw St.

Anchorage, AK 99508

6

Recordkeeping

• Recordkeeping requirements are documented in the Individual Provider Agreement and Tax

Certification and Group Provider Agreement and Tax Certification

• Although most recordkeeping requirements are consistent for all providers, some requirements are

provider-type specific

• Providers must maintain complete and accurate clinical, financial, and other relevant records to

support the care and services for which they bill Alaska Medical Assistance for a minimum of 7 years

from the date of service

• Providers are subject to audits, reviews and investigations

Providers must ensure their staff, billing agents, and any other entities responsible for any aspect of

records maintenance meet the same requirements.

7

Recipient Eligibility

8


Always verify recipient eligibility by using one of the following options:

• Request to see the recipient's eligibility coupon or card that shows the current month of

eligibility; photocopy for your records

• Call Automated Voice Response System (AVR):

– 855.329.8986 (toll-free)

• Verify via Alaska Medicaid Health Enterprise website

– http://medicaidalaska.com

• Fax complete Recipient Eligibility Inquiry Form - General

– 907.644.8126

• Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction

• Call Provider Inquiry

– 907.644.6800, option 1 or 800.770.5650, option 1, 1 (toll-free)

9


The Dental billing manual can be

accessed by going to

http://medicaidalaska.com, hovering

on the Providers tab and clicking on

Billing Manuals

10


11

Covered and Non-Covered Services

12

Covered Services

There are three different categories of dental services:

• Children’s Dental Services

• Adult Emergent Dental Services

• Adult Enhanced Dental Services

Covered services are determined by

• Recipient eligibility category and age

• Annual benefits limit, if applicable

• The rendering provider’s licensure and specialty

The list of covered services are identified on the Dental Fee Schedule

http://manuals.medicaidalaska.com/medicaidalaska/providers/FeeSchedule.asp

13

Dental Fee Schedule Check the Dental fee schedule at http://manuals.medicaidalaska.com/medicaidalaska/providers/FeeSchedule.asp

prior to submitting claims for all services for information about covered services and billing requirements.



14

Covered Services

• Check the Dental Fee Schedule to determine whether:

‒ A specific service is covered

‒ A service authorization is required

‒ Additional documentation is required

• Always consult the fee schedule in effect at the time of service

• Be sure you are utilizing the correct tab for the category of service you are providing

15

Service Categories

16

Services for Children Children under 21 years of age, with proper eligibility,

are covered for comprehensive dental services.

• Preventive, restorative, prosthodontic, and orthodontic dental care are covered for recipients under 21

• Some children’s dental services require service authorization to be reimbursable

For a complete list of specific services, check the Dental fee schedule on the “Children” tab.




17

Adult Emergent Services

• While deemed “emergent”, some services still require a service authorization to be covered

• Check applicable fee schedule for covered services and billing requirements under “Adult Emergent

Services” at http://manuals.medicaidalaska.com/medicaidalaska/providers/FeeSchedule.asp

• Emergent dental services are for immediate relief of pain or acute infection, and may include

– General diagnostic evaluations

– Radiographs

– Anesthesia

– Sedation

– Certain services in preparation for dentures and partials

• Extractions

• Alveoloplasty in preparation for dentures and partials

Emergent dental services are not subject to, and do not reduce the adult recipient’s

annual reimbursement limit under the Adult Enhanced Dental Services.


Adult enhanced services cover non-emergent preventative and restorative dental services for adults age 21

and older.

• recipients receive a $1,150 annual benefit limit; any amount beyond the benefit limit will not be covered

• Annual benefit period is according to the state fiscal year, from July 1st – June 30th

• Consult the Dental fee schedule under “Adult Enhances Services” at


Services may include:

• Preventive care, including

routine diagnostic exams

and X-rays

18

Adult Enhanced Services

• Restorative care

• Dentures

• Periodontics

• Prosthodontics

• Oral Surgery

• Endodontics


19

Adult Enhanced Services

• Recipient may be billed for services exceeding their annual limit only if they are notified in

advance and agree to receive the non-covered services

• The recipient’s record must include documentation verifying that recipient was informed of

limit and that they agree to pay any non-covered charges

• If Medicaid covers any portion the of exceeded service, providers may only charge the

recipient the Alaska Medicaid maximum allowable minus the covered amount

• recipient cannot be billed if provider fails to:

– Obtain a required service authorization prior to rendering services

– Inform the recipient, in advance, of their obligation to pay non-covered services or

recipient does not agree to assume responsibility prior to services being rendered

Provider Note: A recipient’s benefit limit is verified with each service authorization request. If the requested

service exceeds the annual limit, the amount covered, if any, and the patient’s liability will be included. Providers

may use this information to inform a recipient of all non-covered chargers prior to rendering the service. To verify

a recipient’s benefit limit before requesting services, you may contact Provider Inquiry.

20

Covered Services for Children

21

Covered Services for Children

• Office visits are covered for children when the provider prescribes or administers an

antibiotic for an infection, swelling, or pain, but no other service is provided

– If other treatment occurs on the same date, do not bill the office visit

• Space management therapy is covered for children

– Space management therapy is covered only for posterior teeth

– A space maintainer is reimbursable for primary teeth if a significant risk exists of

detrimental drifting occurring before permanent tooth eruption

– A simple space maintainer is reimbursable for permanent teeth when prosthodontic

treatment is not applicable

22

EPSDT Dental Screening

• Under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, oral health

screenings are covered for recipients under 21

• An EPSDT screening must consist of a comprehensive dental screening that meets the minimum

recommendations of the American Academy of Pediatric Dentistry’s

Recommendation for Pediatric Oral Health Assessment Preventative Services, and Anticipatory

Guidance/Counseling, and

Guideline on Periodicity of Examination, Preventative Dental Services, Anticipatory

Guidance/Counseling, and Oral Treatments for Infants, Children, and Adolescents

• Oral health guidelines are also outlined in the American Academy of Pediatrics' Recommendations

for Preventative Pediatric Health Care, also known as the Bright Futures Periodicity Schedule

• Alaska Medicaid will cover additional dental services if determined to be medically necessary as a

result of an EPSDT screening and the screener receives a service authorization as necessary

23

EPSDT Dental Screening

• Oral health screenings should begin at age 6 months and dental exams should begin no

later than age 3 years

• Oral evaluations are limited to one per year for eligible children ages 3 – 21 and two per

year for eligible children under age 3

• A maximum of four fluoride varnish applications are covered per calendar year

• The following provider types who have appropriate training may perform dental fluoride

application and oral evaluations:

– Dentists

– Dental Health Aide Technicians (DHAT)

– Physician/ANP/PA

– Community Health Aides/Practitioners (CHA/P)

• Non-dental providers must complete an Oral Health or Caries Risk Assessment training

program and retain a certificate of completion

24

Orthodontic Services

• Orthodontic coverage and payment details can be found in the Orthodontic Services

Statement of Coverage

• Orthodontic dental services are covered for children

• Service authorization is required for all orthodontic services

• If a recipient loses eligibility, Alaska Medicaid will not cover any remaining treatment, in

which case the recipient’s parent or guardian becomes responsible for payment

• Orthodontic services may be covered when the following conditions are met:

– Limited, interceptive, or comprehensive orthodontic treatment is medically necessary

– The rendering provider holds an appropriate license and specialty to render orthodontic

care. This specialty must be on file with Alaska Medicaid

– The rendering provider or group obtains appropriate service authorization.

• Except for treatment of a cleft palate, orthodontic services will not be authorized for a

recipient with a history of caries during the 6 months prior to proposed treatment

• Orthodontic treatment is limited to once per lifetime

http://manuals.medicaidalaska.com/docs/dnld/Update_Orthodontic_Svcs_Stmt_of_Coverage.pdf

http://manuals.medicaidalaska.com/docs/dnld/Update_Orthodontic_Svcs_Stmt_of_Coverage.pdf

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Limited and Interceptive Orthodontic Treatments

• Interceptive orthodontic treatment is limited to recipients up to 13

• Approval for limited or interceptive orthodontics is not considered approval for any other

orthodontic service

• If the provider anticipates a second phase of orthodontic treatment after beginning limited

or interceptive orthodontic treatment, Alaska Medicaid will require a new Handicapping

Labiolingual Deviation (HLD) Index Report to consider further treatment

• If an additional phase of treatment begins within 18 months of the limited or interceptive

orthodontic treatment, any reimbursement made for the limited treatment will apply toward

the comprehensive plan

• Reimbursement for limited orthodontic treatment includes the appliance(s) and all

medically necessary treatment

26

Comprehensive Orthodontic Treatment

• Providers should consider a recipient’s willingness and ability to attend scheduled

appointments and maintain an acceptable level or oral hygiene before requesting an SA

for this service

• Recipients must have an HLD score of 26 or greater to qualify for comprehensive

– Providers must submit a description of medical necessity describing functional

impairment to support this score

• Alaska Medicaid reimburses for initial placement when the appliance placement date and

date of service are the same

– Initial placement include the first three months of treatment and the appliance

• When periodic orthodontic treatment as part of a contract is approved, providers may bill

for three units of service; Alaska Medicaid expects providers to bill 1 unit of service at 6

months, 12 months, and after removal of the appliance

27

Discontinuing Orthodontic Treatment

• If an orthodontist determines that treatment should be discontinued as a result of non-

compliance or Medicaid/Denali KidCare ineligibility, the orthodontist must remove and

replace brackets with retention if needed

• Termination due to non-compliance is left to the provider’s discretion

– In the event of termination, the orthodontist must submit a statement reporting

termination of treatment to the Service Authorization Unit within 30 days of termination

28

Covered Services for Children and Adults

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Covered Services

• To determine whether a specific service is covered and whether the service requires a service

authorization, refer to the Dental Fee Schedule

• Diagnostic evaluations are covered for routine dental care

• Radiographs are also covered as needed to diagnose and treat routine emergent care

• For adult recipients, coverage is limited to:

– 1 periodic evaluation or comprehensive evaluation per fiscal year

– 1 panoramic radiograph per calendar year

• Endodontic care is covered, with certain limitations:

– Palliative and sedative treatments cannot exceed 2 times per tooth before a definitive treatment

– Pulp capping is covered when necessary for direct pulp caps of exposed pulps of permanent teeth

– Tooth preparation, filling the root canal, and follow up care are included in the fee for root canal

therapy and cannot be billed separately

– Pin retention and restoration may be billed separately, but claims cannot exceed 5 surfaces per

tooth

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Oral Surgery and Periodontic Services

• The fee for oral surgery includes local anesthesia, materials, and routine postoperative

care – these services cannot be billed separately

• Periodontic treatment may be covered, including treatment of pain or acute infection of

supporting tissues of the teeth, including:

– Necrotizing ulcerative gingivitis

– Acute primary herpetic gingivostomatitis

– Dilantin hyperplasia

– Periodontitis

– Periodontal abscess

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Preventive Services

• Preventive services for adults are covered as part of the enhanced adult dental benefit

• The following preventive services are covered for adults:

– Prophylaxis, including necessary scaling, polishing, and instruction on oral hygiene up

to 2 times per fiscal year

– Topically applied fluoride treatment up to 4 times per fiscal year

• The following preventive services are covered for children:

– Prophylaxis up to 2 times per calendar year

– Topically applied fluoride treatment up to 4 times per calendar year

– Dental sealants up to 1 per calendar year per tooth

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Restorative Services

• Restorative care is covered, including amalgams and resin restorations

• Treatment must be for decayed or fractured teeth

• When a tooth cannot be restored with amalgams or resin, Alaska Medicaid will cover:

– Preformed stainless steel or preformed plastic crowns for children

– Stainless steel crowns and full crowns for adults

• Restorations are limited to no more than 5 surfaces per tooth for both children and adults

• Tooth preparation, sedative and cement base, and local anesthesia are included in the fee

for the complete procedure and cannot be billed separately

33

Denture Preparation Services

• Certain services rendered in preparation for dentures or partials do not count against a

recipient’s annual reimbursement limit, including:

– Extractions

– Alveoplasty

• Immediate dentures are not covered by Alaska Medicaid

• Providers must wait a minimum of 8 weeks following extraction of teeth before beginning

denture fabrication and placement process

• A service authorization is required for all denture-related services

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Denture Services

• Dentures are allowed $1,150 for single or $2,300 for double dentures per year which will

use 2 years of the recipient’s benefits

• Denture replacements are limited to once per 5 calendar years for partial or complete

dentures and only with medical necessity

– Replacement - partial with a complete denture may not be earlier than 5 years after

payment for the partial denture

– Same Dental Arch - are limited to no more than 3 per lifetime

– Adjustments - to complete or partial dentures not more than 4 times per calendar year

– Rebase and Reline - once per 3 calendar years for complete dentures

• A service authorization is required for all denture-related services

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Dental Anesthesia and IV Sedation

• General anesthesia (D9223) and IV sedation (D9243) require medical justification for both

children AND adults when administered by a dentist

– Claims for these service will be denied if medical justification is not submitted with the claim

• Dental-related anesthesia and IV sedation are covered only when:

– Medically necessary

– Provided in conjunction with a covered dental service

– All other conditions for reimbursement have been satisfied

• General anesthesia or intravenous sedation are covered only when:

– Local anesthesia and non-sedation are inadequate to control pain AND

– The patient has a severe intellectual or developmental or physical disability or medically-

compromised condition or the surgical procedure is prolonged or difficult

36

Prescription Medications

Preferred Drug List (PDL)

Alaska Medicaid covers prescription medications when

prescribed or dispensed by an enrolled dentist

Non-Preferred Drugs

• The Preferred Drug List was developed in

an effort to select both clinically sound and

cost effective medications for use by those

eligible for Alaska Medicaid

• Applicable service authorization

requirements and maximum quantity limits

are indicated on the PDL

Prescription orders for non-preferred medication must include

documentation of medical necessity, such as:

• Patient allergy

• Contraindications

• FDA approved multiple indications

• Ineffective treatment

http://dhss.alaska.gov/dhcs/Pages/pharmacy/medpriorauthoriz.aspx

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Prescription Medication

• Alaska Medicaid will not pay for a brand name medication if a therapeutically equivalent generic

medication is available unless:

– The brand name medication is on the Preferred Drug List; or

– The prescriber indication medical necessity on the prescription; or

– The prescriber submits the prescription telephonically with instructions that the brand name

medication is medically necessary and documents it in the recipient’s medical record

• Certain medications require a service authorization before they can be covered – refer to the Prior

Authorized Drug List or the Interim Prior Authorization List for requirements

http://dhss.alaska.gov/dhcs/Documents/pharmacy/Documents/Pa-Drug-list.pdf


http://dhss.alaska.gov/dhcs/Documents/pharmacy/Documents/InterimPriorAuthorizationList.pdf

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Prescription Medication (cont.)

• Medications not prescribed by electronic transmission or by oral communication must be

written on temper-resistant paper or printed on plain paper with tamper-resistant features

• Tamper-resistant paper or tamper-resistant printing must include at least:

– 1 industry-recognized feature designed to prevent erasure or modification of information

written on the prescription

– 1 industry-recognized feature designed to prevent use of counterfeit prescription forms

• Any 1 feature may not be used more than once for proof of temper resistance

• Prescriptions must also contain the prescriber’s National Provider Identifier (NPI)

39

Non-Covered Services for Children

The following dental services are not covered for children, unless determined to be medically

necessary during an EPSDT screening and the screener received a service authorization:

• Services the exceed maximum allowable limits

• Indirect pulp capping

• Space maintainers for anterior teeth

• Deep groove restoration without obvious dentin involvement

• Denture characterization and personalization, implants and precision attachments

• Experimental procedures

• Incomplete or in-progress dental services

• Photographs

40

Non-Covered Services for Children

The following dental services are not covered for adults:

• Services that exceed maximum allowable limits

• Dental sealants

• Deep groove restoration without obvious dentin involvement

• Inlays, overlays or three-fourth crowns

• Endodontic apical surgery or retrograde fillings

• Periodontal surgery

• Implant or implant-related dental services

• Orthodontic services

• Incomplete or in-progress dental services

• Photographs

41

Service Authorization

42

Service Authorizations

As with any healthcare specialty, some provided services require a service authorization

(SA) prior to rendering services.

• All adult enhanced dental services require an SA

– Annual benefit limit ($1150) is reviewed as part of the approval process

– SA approvals will include an estimate of the patient’s liability when requested services

exceed the remaining benefit balance

• Some adult emergent and children's dental services require an SA

– Approved emergent service SAs do not count against the enhanced services annual

benefit

Review the Dental Fee Schedule for all services requiring an SA


43

Service Authorization Time Limits

• As of July 1, 2018, service authorizations for dental appliances, such as crowns, dentures,

etc., will be valid for 90 days from the date the authorization was requested

• If the approved service does not occur within the 90 day period, the provider must

complete and submit a Dental Service Authorization Update Request form

• Except for orthodontic services, authorization approvals for all other dental services will be

valid for the requested date of service only

• If the scheduled service does not occur on the requested date, the provider must complete

and submit an authorization update request form

44

Obtaining a Service Authorization

Dental services require a dental-specific authorization form.

Complete the Dental Service Authorization (SA) Request

form located at

http://manuals.medicaidalaska.com/docs/dnld/Alaska_Form

_DentalAuthv2.pdf

• Mail to:

Conduent Service Authorization

P.O. Box 240808

Anchorage, Alaska 99524-0808

• Fax to:

Conduent Services at 907.644.9861

Provider Note: Double-check your form prior to submitting it! There are many types of service

authorization forms located on http://medicaidalaska.com, including a generic one titled Service

Authorization Request Form. This form can not be used for dental SAs.

45

Update a Service Authorization

46

Orthodontic Service Authorization

All orthodontic services require a prior authorization request submitted by the orthodontist that

includes comprehensive medical justification and a treatment plan.

• The authorization request must include:

– a description of the condition including medical information to determine functional impairment

– a description of the orthodontic appliance

– a scored Handicapping Labiolingual Deviation (HLD) Index Report completed and signed by the

orthodontist

– a written, comprehensive orthodontic treatment plan

– panoramic films

– intraoral and extraoral photographs

– Other pertinent medical or dental information to support the requested treatment, if applicable

– an Orthodontic Referral Oral Health and Hygiene Assessment completed and signed by the

referring dentist

47

Orthodontic Service Authorization

Extending an Orthodontic Service Authorization

• An extension request should be faxed to Conduent at 907.644.9861

• It must include:

– Reason(s) the treatment could not be completed within the originally authorized

timeframe

– New estimated date of completion for treatment

– Any supporting documentation to justify extending the length of treatment

48

Prescription Medication Service Authorizations

• Certain medications require a service authorization before they can be covered – refer to

the Prior Authorized Drug List or the Interim Prior Authorization List for requirements

• Unless otherwise indicated, the prescriber must request an authorization by calling

Magellan’s Medicaid Administration Clinical Call Center or faxing them a completed form

• Authorization forms can be found at:

– Conduent Pharmacy Updates and Forms page

– DHCS Medication Prior Authorization page

– Magellan Medicaid Administration Clinical Call Center at 800.331.4475


http://dhss.alaska.gov/dhcs/Documents/pharmacy/Documents/InterimPriorAuthorizationList.pdf

http://manuals.medicaidalaska.com/docs/pharmacy.htm

http://dhss.alaska.gov/dhcs/Pages/pharmacy/medpriorauthoriz.aspx

49

Service Authorizations

Helpful Tips:

• SAs must be requested under your Alaska Medicaid billing ID instead of the dentist’s

individual ID; if your practice has multiple locations, use the Billing ID for the specific

location services will be performed

– This would allow other dentists in the group to render services if the original provider is

unavailable on the scheduled procedure date

• The procedure won’t need to be rescheduled and the group can still bill for services

under the original SA

• Update existing SAs when additional services are required to ensure new/changed

services won’t exceed annual benefit limit

• Cancel any SAs that have been authorized but not used

– Future SA approvals are dependent on accumulated services requested

50

Third-Party Liability

51

Third Party Liability (TPL)

• Dental providers are required to bill TPL, except for IHS coverage, before billing Alaska Medicaid

• TPL billing must be documented on the claim to Alaska Medicaid, and the EOB from the TPL must

be included with the claim as an attachment

• If the EOB from the TPL includes any resolution coding, that information must be included with the

EOB to allow for accurate and timely processing

• TPL reimbursement is compared to the Alaska Medicaid maximum allowable amount

If the amount on the TPL EOB exceeds the

Alaska Medicaid allowed amount, no

additional amount will be paid.

If the amount on the TPL EOB is less than

the Alaska Medicaid allowed amount,

Alaska Medicaid will pay the difference.

52

TPL Verification

How can I tell if a recipient has other coverage?

• Alaska Medicaid eligibility coupons and cards

– Resource code / carrier code

• Automatic Voice Recognition (AVR) system

– 855.329.8986 (toll-free)

• Look up the recipient’s eligibility information in Health Enterprise


• Provider Inquiry

– 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2

• You can review the specific carrier codes on http://medicaidalaska.com under

Documentation>Documents & Forms>TPL Carrier Lookup

http://medicaidalaska.com/


53

TPL Spans in Health Enterprise

TPL Spans in Health Enterprise

54

TPL Carrier Lists can be found on

http://medicaidalaska.com

• Documentation > Documents & Forms

• Select TPL Carrier Lookup

TPL Verification

55

If the recipient is covered under another government program, they will have one or more of these resource codes on their eligibility documents.

Government Agency

Resource Codes

G/H/J

Medicare

M

Tricare

N

Veterans

Administration

(VA)

N2

Veterans Greater

than 50%

Disabled

P

Alaska Area

Native Health

Services

Y

No Other

Insurance

Resource Codes

56

57

TPL Carrier Code List

• The TPL Carrier Code List is available from the Conduent website:


– Documentation > Documents & Forms > TPL Carrier Lookup

• It is updated monthly

• This lookup is useful in conjunction with the recipient card or coupons to determine if there

is another insurance carrier that should be billed prior to billing Alaska Medicaid

• A recipient’s TPL information will also be listed when performing an eligibility check on the

Health Enterprise portal


58

Carrier Code List Example

59

Dental Claims

60

Electronic Claims Submission

There are different methods for submitting claims electronically.

• Alaska Medicaid Health Enterprise portal - medicaidalaska.com

• HIPAA-Compliant Practice Management Software

• Payerpath - http://www.payerpath.com

– Free internet-based data entry program

Electronic transactions have many benefits:

• Standardized submission method

• Faster processing

• Fewer errors

• Reduced paperwork or manual processing

• recipient eligibility and claim status checks

Electronic Transactions

Any provider choosing electronic claims

submission must complete the Provider,

or Billing Agent, Information Submission

Agreement and successfully test all

desired electronic transactions.

For more information, contact EDI Dept.

907.644.6800, option 3

800.770.5650, option 4 (toll-free)

Companion Guide –

http://manuals.medicaidalaska.com/do

cs/companionguides.htm

Implementation Guide –

http://www.wpc.edi.com

61

ADA Dental Claim Form

The most current ADA form is the 2012 version.

• J430, J430D, J431, J432, J433, or J434

• All are the same form but different media

• This claim form was created and is maintained by the American

Dental Association

• General claim form instructions are available at

https://www.ada.org/en/publications/cdt/ada-dental-claim-form

• Alaska Medicaid specific claim form instructions are available at

http://manuals.medicaidalaska.com/docs/dnld/Billing_ADA_2012

_Instructions.pdf









http://manuals.medicaidalaska.com/docs/dnld/Billing_ADA_2012_Instructions.pdf



62


Type of Transaction (field 1) mandatory:

Select “Statement of Actual Services”

Predetermination/Preauthorization Number (field 2) conditional:

Enter the applicable Alaska Medicaid service authorization number

Insurance Company/Dental Benefit Plan Information (field 3)

mandatory:

Conduent State Healthcare LLC

P.O. Box 240769


Other Coverage (fields 4-11) conditional:

Select whether other coverage is dental or medical; If marked, complete

boxes 5 – 11.

If none, leave blank. If both, complete for dental coverage only.

63


Policyholder/Subscriber Information (field 12) mandatory:

enter patient’s full name and address

Date of Birth / Gender (fields 13-14) mandatory:

enter patient’s DOB and gender

Policyholder/Subscriber ID (field 15) mandatory:

enter patient’s Alaska Medicaid ID number

Plan/Group Number (field 16) blank:

leave blank

Employer Name (field 17) optional:

enter name of patient’s employer

Patient Information (fields 18-22) optional:

if used, mark “Self” in field 18; leave fields 19-22 blank

Patient ID/Account # (field 23) optional:

enter patient’s record or account number; for dental provider record keeping purposes only

and will appear after claim control number on remittance advice

64


Procedure Date (field 24) mandatory: enter date service was rendered

Area of Oral Cavity (field 25) conditional: enter when the procedure code in field 29 refers

to quadrant or arch that is not specifically identified in the procedure’s description

Tooth System (field 26) optional: optional reporting

Tooth Number(s) and Letter(s) (field 27) conditional: enter the appropriate tooth

number/letter when the procedure directly involves a tooth, otherwise leave blank; if the

same procedure is performed on more than one tooth on the same date, report each

procedure and tooth as a separate line item

(See next slide for supernumerary/quadrant codes)

Tooth Surface (field 28) conditional: if the procedure involves one or more tooth surfaces

annotate all that apply with no spaces between surface designators

B – Buccal F – Facial (Labial) L – Lingual O – Occlusal

D – Distal I – Incisal M – Mesial

Refer to your fee schedule

for required tooth and

surface identification. Do

not include any notes in

this area. Reserve all

pertinent notes for field 35,

Remarks.

65


When reporting supernumerary teeth, use proper CDT

manual references.

If you need to report quadrant information, include code

area in field 25.

Valid Code Areas

• 00 Entire Oral Cavity

• 01 Maxillary Arch

• 02 Mandibular Arch

• 10 Upper Right Quadrant

• 20 Upper Left Quadrant

• 30 Lower Left Quadrant

• 40 Lower Right Quadrant

66


Procedure Code and Quantity (field 29, 29b) mandatory: enter the dental procedure code

that describes the service and number of units provided; no more than 10 lines per claim

− If multiple units of the same procedure were provided, enter the total units on one line.

For example, if providing D9223, Deep Sedation, for 45 minutes, a total of three units

would be reported in field 29b because each 15-minute increment is one unit.

Diagnosis Pointer (field 29a) conditional: if a diagnosis code is entered in field 34a,

Diagnosis Code(s), enter the corresponding line’s letter (A,B,C, or D) here

Description (field 30) mandatory: enter brief description of service provided (not justification)

Fee (field 31) mandatory: report full fee for each procedure

Other Fee(s) (field 31a) conditional: enter applicable additional fees, otherwise leave blank

Total Fee (field 32) mandatory: enter total of all fees (field 31 and 31a)

67


Missing Teeth Information (field 33) mandatory: enter any applicable missing teeth;

missing teeth should be reported when pertinent to Periodontal, Prosthodontic (fixed and

removable), or Implant Services procedures on a particular claim

− Primary Teeth designation has been removed from 2012 version

Diagnosis Code List Qualifier (field 34) conditional: if a diagnosis code is entered in field

34a, Diagnosis Code(s), an ICD-9(B) or ICD-10(AB) qualifier must be entered

− You may not mix ICD-9 and ICD-10 codes on a single claim

Diagnosis Code(s) (field 34a) optional: if used, enter the primary diagnosis code on line “A”;

if multiple diagnosis codes apply, enter secondary ones on lines “B” - “D”

− Dental claims do not require diagnosis codes at this time

Remarks (field 35) conditional: enter applicable Third Party Liability amounts

− Additional documentation must be attached to claim as needed for further justification

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Authorizations (fields 36, 37) optional: Alaska Medicaid recipients do not need to sign the

dental claim form, but providers must have consent to perform any dental procedures;

providers may insert “Signature on File”

Place of Treatment (field 38) mandatory: enter appropriate 2-digit “Place of Service” code;

list available at www.cms.gov/PhysicianFeeSched/Downloads/Website_POS_database.pdf

Frequently used “Place of Treatment” codes are:

11 = Office 21 = In. Hospital 31 = Skilled Nursing Facility

12 = Home 22 = Out. Hospital 32 = Nursing Facility

Enclosures (field 39) mandatory: enter “Y” or “N” in box

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• Is Treatment for Orthodontics? (fields 40-42) mandatory: if “No”, skip to field 43; if “Yes”,

complete fields 41, Date Appliance Placed, and 42, Months of Treatment Remaining

• Replacement of Prosthesis (fields 43, 44) mandatory: if “No”, skip to field 45; if “Yes”,

complete field 44, Date of Prior Placement

• Treatment Resulting from (fields 45-47) conditional: check all that apply; complete fields

46, Date of Accident, and 47, Auto Accident State, as applicable

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Billing Dentist or Dental Entity (fields 48-52a) mandatory: enter the billing group’s name, address,

city, state, and zip code+4, NPI, license number (optional), SSN or TIN (optional), phone number

(optional), and Medicaid ID (conditional) associated with the group enrollment file

*This information must match the information on any service authorization or claim will deny; also,

make sure all of the information is consistent with the same provider or group.

For example: If provider A rendered services, then use provider A’s name, address, NPI, license

number, SSN/TIN, phone number, and taxonomy number. If a group is billing for services rendered,

all information in this area should be associated with the group.

Treating Dentist and Treatment Location Information (fields 53-57) mandatory: treating dentist

must sign/date; enter treating dentist’s NPI, license number, physical treatment location, treating

provider’s specialty code (taxonomy), phone number (optional)

Only the Group Enterprise ID

will be accepted here.

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Dental Provider Specialty/Taxonomy

Provider Specialty Code (field 56a)

conditional: if applicable, enter the

appropriate provider specialty

(taxonomy) of the treating provider; this

must match Alaska Medicaid provider

enrollment records

Her are some commonly used Dental

Provider Taxonomy Codes. A complete

list of taxonomy codes can be found at

http://www.wpc-edi.com/reference/.

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Dental Claims in Health Enterprise

To submit claims using Alaska Medicaid Health Enterprise, log in to

https://medicaidalaska.com/

• Under the Claims tab, expand Create Claims, and click on Create Dental Claim

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Additional Information

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Overpayments & Repayment of Payment Errors

Providers should closely review each remittance advice (RA) to ensure it reflects accurate

payment for all billed services, including correct recipient details and services provided.

• In accordance with 7 AAC 105.220(e), Alaska Medical Assistance providers have 30 days

from the time of payment to notify the department in writing of a payment error.

• Federal law (42 U.S.C. 1320(d)) requires repayment of overpayments to the department

within 60 days of identifying the overpayment.

• Mail the written overpayment notification and a copy of the RA page detailing the

overpayment to the address below:

Conduent State Healthcare, LLC

P.O. Box 240807


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Additional Resources

Alaska Medicaid Health Enterprise website at http://medicaidalaska.com.

• Information necessary for successful billing

• Includes provider-specific Medicaid billing manuals and fee schedules

– Dental Billing Manual

– Dental Fee Schedule

– Dental Claim Form Instructions

You may also call:

• Provider Inquiry

– Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2

– Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-free),

option 1,1,1

http://manuals.medicaidalaska.com/dental/dental.htm

