South Carolina Department of Health and Human Services (SCDHHS) Dental Program Dental Office Reference Manual Updated: 04/08/2013 DentaQuest, LLC 1333 Main Street, Suite 603 Columbia, SC 29201 Phone 888.307.6553 www.dentaquest.com This document contains proprietary and confidential information and may not be disclosed to others without written permission. April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). 2 DentaQuest, LLC Address and Telephone Numbers DentaQuest’s South Carolina Office Dental claims should be mailed to: 1333 Main Street, Suite 603 DentaQuest, LLC - Claims Columbia, SC 29201 PO BOX 2136 Columbia, SC 29202-2136 PROVIDER CALL CENTER 888.307.6553 Electronic Claims should be sent: Via the web - www.dentaquest.com Fax: 800.461.2640 Via Clearinghouse IVR: 888.307.6553 DentaQuest Systems Corporation 12121 N. Corporate Parkway Via email - Mequon, WI 53092 Claims questions: 3 DentaQuest makes every effort to maintain accurate information in this manual; however, DentaQuest will not be held liable for any damages directly or indirectly due to typographical errors. Please contact us should you discover an error. The Dental Services Provider Manual is composed of both the General Information and Administration section of the South Carolina Healthy Connections Manual (See Appendix E) and the South Carolina Healthy Connections Dental Office Reference Manual. April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). 4 Date Section Page(s) Change 4/8/13 Cover Updated publication date 2 Removed obsolete email address 4.02 21 Updated list of clearinghouses for electronic claim submission 4.03 22 Updated email address for questions on electronic claim submission Appendix Updated SCDHHS Dental Services Provider Manual Section 1 E Exhibits Corrected limitation on the following codes: A and C D2950, D2954 Exhibits Added language on biopsies on biopsies of oral tissue to covered A, B, and oral surgical codes C 1/15/13 Contacts 2 Added SCDHHS Fraud and Abuse email address Provider Rights & Updated Provider Responsibilities to include adherence to state and 8 Responsi federal requirements for the practice of dentistry. -bilities 4.10 26 Clarified timely filing policies 7.05 33 Added SCDHHS Fraud and Abuse email address 9.01 35 Updates SCDHHS Requirements for Provider Participation Appendix 37 Corrected definition of clean claim A Appendix 40 Added reference to ADA standard for tooth numbering B Appendix 49 Added criteria for the use of behavior management C Appendix 50-51 Clarified documentation requirements for dental record D Appendix Updated SCDHHS Dental Services Provider Manual Section 1 E Exhibits Replaced CDT Codes D1203 and D1204 with D1208 A and C Exhibits Clarified guidance on same tooth restorations done within six month A, B, and timeframe, extractions and orthodontia, and sedation/anesthesia C billing and documentation. Appendix 10/2/12 Updated SCDHHS Dental Services Provider Manual Section 1 E 8/2/12 9.00 35 Added link to electronic contact for Provider Enrollment Appendix Updated SCDHHS Dental Services Provider Manual Section 1 E 5/1/12 10 Updated Table of Contents April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). 5 1.00 13 Updated language on adult coverage 2.01 15 Updated language on adult coverage 2.06 18 Updated language on adult coverage 4.06 and 24-25 Updated language on adult coverage 4.07 Appendix 40 Updated language on adult coverage B Appendix Updated SCDHHS Dental Services Provider Manual Section 1 E 4/2/12 2.01 13 Updated sample member card Appendix Updated SCDHHS Dental Services Provider Manual Section 1 E 2/2/12 2 Updated email address for dental claim submission Added reference to addition of SCDHHS Provider Manual Section 1 3 as Appendix E 2.01 15 Updated language on adult coverage 2.06 18 Updated language on adult coverage 2.07 18 Included information on broken appointment tracking 4.03 22 Updated email address for dental claim submission 4.06 24 Updated language on adult coverage 4.07 24-25 Updated language on adult coverage 4.12 26 Clarified language on timeframe for appeal requests 4.14 27 Clarified language on dental charges associated with OR/ASC usage 6.01 30 Clarified language on timeframe for appeal requests Appendix 40 Updated language outlining available benefits B Appendix 50 Included information on broken appointment tracking D Appendix Added Dental Services Provider Manual Section 1 E 8/19/11 2.06 18 Updated beneficiary transportation information Removed reference to copayment requirements for MR/RD Waiver 4/14/11 2.04 17 members 4/7/11 1.00 13 Clarified language related to adult coverage 1.02 13 Updated Provider Relations phone number April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). 6 2.01 15 Clarified language related to adult coverage 2.04 17 Updated copayment requirements 2.06 18 Updated language related to adult coverage Clarified review processes for prepayment review (PPR) and prior 3.0 19 authorization (PA); clarified language related to adult coverage 4.06 24 Clarified language related to adult coverage 4.07 24 Clarified language related to adult coverage 4.08 25 Updated copayment requirements 4.15 27 Updated Provider Enrollment phone number 4.16 28 Updated terminology for web portal 6.00 30 Clarified appeal process 9.00 35 Updated Provider Enrollment phone number Appendix 37 Added definition for “medical condition” A Appendix 40 Clarified language related to adult coverage B Exhibits Updated the following codes: A-C D0140, D0240 Clarified language related to adult coverage; removed the following Exhibit B codes: 40700, 40701, 40702, 40720, 40761 10/21/10 2 Added fax number for submitting appeals Added instruction for submission of emergency authorization 3.03 20 requests 4.06 24 Clarified methods for indicating emergency services Updated the limitation of following codes: Exhibit A D0140, D0150, D0240, D0330, D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2392, D2393, D2394 Updated the limitation of following codes: Exhibit B D0140, D0240, D7140, D7210 Updated the limitation of the following codes: D0120, D0145, D0150, D1110, D1120, D1203, D1204, D1206, D1351, D1510, D1515, D0210, D0270, D0272, D0330, D5110, Exhibit C D5120, D5211, D5212, D5510, D5520, D5610, D5640, D0140, D0240, D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2392, D2393, D2394 Appendix 7/12/10 40 Added instruction for tooth surface designation. B Revised instructions for codes requiring review and authorization Exhibits requirements for planned Hospital or Ambulatory Surgical Center A - C (ASC) usage. D9420 (hospital call) is to be included in authorization requests for planned Hospital or ASC usage. April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). 7 Updated descriptions of the following codes: 21116, 21497, 31000, 31020, 31030, 31603, 31605, 40500, 40510, 40520, 40530, 40650, 40652, 40654, 40700, 40701, 40702, 40720, Exhibits 40761, 41000, 41008, 41009, 41015, 41016, 41017, 41018, 41112, A – C 41113, 41116, 41120, 41130, 41135, 41140, 41145, 41150, 41155, 41250, 41252, 41828, 42106, 42120, 42200, 42220, 42225, 42235, 42260, 42330, 42335, 42408, 42409, 42440, 42450, 88160 Updated descriptions of the following codes: D0120, D0145, D0150, D7280, D7550, D7671, D7771, D7910, Exhibit A D7911, D7912, D9420, 21210, 21215, 21240, 21242, 21243, 21340, 21356, 21360, 21365, 21385, 21423, 21433, 21436, 21454, 21461, 21462, 31040, 41874, 42205, 42210, 42215, 42550 Updated descriptions of the following codes: D0140, D0210, D0220, D0230, D0240, D0270, D0272, D0330, D7550, D7910, D7911, D7912, D9230, D9248, D9420, D7671, Exhibit B D7771, D9230, 20900, 20902, 21029, 21210, 21215, 21240, 21242, 21243, 21340, 21356, 21360, 21365, 21385, 21423, 21436, 21454, 21461, 21462, 31040, 42200, 42205, 42210, 42215, 42550, 88300 Updated the following codes: D7550, D7910, D7911, D7912, D9420, 21210, 21215, 21240, Exhibit C 21242, 21243, 21340, 21356, 21360, 21365, 21385, 21423, 21433, 21436, 21454, 21461, 21462, 31000, 31040, 41874, 42205, 42210, 42215, 42550 Exhibit C Changed Age Limitation from “All” to “21 and Older” 6/21/10 All Removed references to Healthy Connections Kids (HCK) Clarified federal claim filing guidelines for dually eligible Medicare 2.05 17 and Medicaid recipients. 3.01 19 Revised definition of prior authorization. Appendix Clarified criteria for dental extractions do no extend to prophylactic 49 C removal of asymptomatic teeth such as third molars. Expanded value-added service language regarding authorization 6/10/10 1.05 14 coordination. Added clarification that “authorization” can be obtained via a prior 3.01 19 authorization or pre-payment review. 4.02 22 Updated address for claim submission. 4.05 23 Updated paper claim completion instructions. Clarified that complaint or appeal requests must be received within 6.01 30 30 calendar days. Appendix 37 Revised definitions for “clean claim” and “prior authorization.” A Appendix Updated documentation and procedure criteria to reflect what’s 42 C necessary for prepayment review as opposed to prior authorization. Appendix Dental Record recommendation language changed from “must” to 50 D.2 “should.” April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). 8 Healthy Connections Statement of Provider Rights and Responsibilities Providers shall have the right to: 1. Communicate with Beneficiaries regarding dental treatment options. 2. Recommend a course of treatment to a Beneficiary, even if the course of treatment is not a covered benefit, or approved by the Healthy Connections program. 3. File an appeal or complaint pursuant to the procedures of Healthy Connections. Supply accurate, relevant, and factual information to any Beneficiary in connection with an appeal or complaint filed by the Beneficiary. 4. Object to policies, procedures, or decisions made by Healthy Connections. 5. Charge an eligible Healthy Connections Beneficiary for dental services that are not Medicaid covered services only if the Beneficiary knowingly elects to receive the services as a private-pay patient and enters into an agreement in writing to pay for such services prior to receiving them. Non- covered services include: services not covered under the Healthy Connections plan and services for which prior authorization has been denied and deemed not medically necessary. 6. Determine to what extent they will participate in the Healthy Connections program (i.e. set patient panel size). However, providers may not discriminate in selecting the Medicaid beneficiaries they will treat or services they will render. Providers have the responsibility to: 1. Protect the Beneficiaries’ rights to privacy. 2. Comply with any applicable Federal and State laws that pertain to Beneficiary rights and not to discriminate against a Beneficiary on the basis of age, sex, race, physical or mental handicap, national origin, ethnicity, religion, sexual orientation, genetic information, economic status, source of payment or type, or degree of illness or condition. A provider may not refuse to furnish services covered under the plan to an individual who is eligible for medical assistance under the plan on account of a third party's potential liability for the service(s). Reference: 42CFR447.20(b) 3. Notify Medicaid Provider Enrollment of any changes in their practice information, including: location, telephone number, limits to participation, Providers joining or leaving the practice, etc. via the Provider Update form, Attachment A-2. 4. Hold the Healthy Connections Beneficiaries harmless and shall not bill any Beneficiary for services if the services are not covered as a result of any error or omission by Provider. 5. Adhere to the Healthy Connections Provider Participation Agreement and all state and federal requirements regarding the practice of dentistry when providing services to Medicaid Beneficiaries. * * * April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). 9 Healthy Connections Statement of Beneficiaries Rights and Responsibilities Medicaid Enrolled Beneficiaries have Rights to the following regarding services received from a Medicaid provider: 1. Civil Rights The Healthy Connections enrolled providers cannot discriminate or mistreat a Medicaid eligible beneficiary because of race, sex, age, handicap, religion, national origin, political belief or limited English proficiency. If a Beneficiary feels they have not been treated fairly, they may call 1-803- 898-2605 or 1-800-368-1019. 2. Health Information Rights The Healthy Connections program provides to the beneficiary a Notice of Privacy Practices with the beneficiary ID Card. This explains how health information about the beneficiary can be used or released. To obtain an additional copy of this notice, please call 1-888-549-0820 (toll-free). 3. Beneficiary Appeals Beneficiaries have the right to appeal to DentaQuest any adverse decision DentaQuest has made to deny, reduce or delay dental services. (Refer to Section 6.02 of this Dental ORM) 4. Beneficiary Complaints (Grievances) Beneficiaries may submit complaints to DentaQuest telephonically or in writing on any Healthy Connections dental program issues other than decisions that deny, delay, or reduce dental services. (Refer to Section 6.02 of this Dental ORM) 5. State Fair Hearing Beneficiaries have the right to request a State Fair Hearing from SCDHHS after any appeal to DentaQuest has been completed (Refer to Section 6.02 of this Dental ORM) 6. Freedom of Choice Except as otherwise specified in this manual, a Healthy Connections beneficiary has the right to choose any provider who is both enrolled in the Medicaid program and willing to accept the beneficiary as a patient. April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). 10 Dental Office Reference Manual Table of Contents Section Page 1.00 What is Healthy Connections?.......................................................................................................13 1.01 Dedicated Call Center for Providers......................................................................................13 1.02 Provider Training ...................................................................................................................13 1.03 Provider Newsletters .............................................................................................................13 1.04 DentaQuest Website .............................................................................................................14 1.05 Other Value-Added Provider Benefits ...................................................................................14 2.00 Beneficiary Eligibility Criteria and Verification Processes..............................................................15 2.01 Eligibility and Identification Card Samples ............................................................................15 2.02 DentaQuest Eligibility Systems .............................................................................................16 2.03 Documenting Beneficiary Eligibility .......................................................................................16 2.04 Beneficiary Co-Payments......................................................................................................17 2.05 Dual Eligibility ........................................................................................................................17 2.06 Beneficiary Transportation ....................................................................................................18 2.07 Broken/Cancelled/Missed Appointment ................................................................................18 3.00 Authorization for Treatment ...........................................................................................................19 3.01 Treatment Requiring Authorization – Prior Authorization and Prepayment Review .............19 3.02 Authorization Requirements for Operating Room (OR) and Ambulatory Surgical Center (ASC) Cases..........................................................................................................................20 3.03 Expedited Prior Authorizations for Emergency Services ......................................................20 3.04 Payment for Non-Covered Services......................................................................................21 3.05 Electronic Attachments..........................................................................................................21 4.00 Claim Submission Procedures (claim filing options)......................................................................22 4.01 Electronic Claim Submission Utilizing DentaQuest’s Website ..............................................22 4.02 Electronic Claim Submission via Clearinghouse...................................................................22 4.03 HIPAA Compliant 837D and 837P File .................................................................................22 4.04 NPI Requirements for Submission of Electronic Claims .......................................................23 4.05 Paper Claim Submission .......................................................................................................23 4.06 Filing Claims for the Provision of Emergency Medical (CPT) Procedures to Adults.............24 4.07 Filing Claims for the Provision of Adult Services for Exceptional Medical Conditions ..........24 4.08 Coordination of Benefits (COB).............................................................................................24 4.09 Fee Schedule and Charge Limits ..........................................................................................25 4.10 Filing Limits............................................................................................................................26 4.11 Claims for Retro-Eligible Beneficiaries..................................................................................26 4.12 Claims Appeals......................................................................................................................26 4.13 Receipt and Audit of Claims..................................................................................................26 4.14 Claim Submission and Payment for Operating Room (OR) or Ambulatory Surgical Center (ASC) Cases............................................................................................................................................27 April 8, 2013 SC Healthy Connections_ORM Current Dental Terminology © American Dental Association. All rights reserved. CPT® codes, descriptions and other data only are copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA).