CareSource

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• CareSource
• Dental Program
• September 9, 2008
• 1200 100

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Welcome!

• Introductions
• Dr. Terry Torbeck, Vice President/Senior Medical
  Director
• Dr. Gary Ensor CSMG Dental Consultant
• Cheryl Slagle, RN, CMCN, CCM
• Director Medical Management
• Meloney Porter, RN Team Lead for Dental Services
• Candace Owens, Senior Dental Coordinator

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Agenda

• Review Adult Dental Benefit changes
• Review communications sent to providers including
  benefit and prior authorization changes
• Review CareSource prior authorization
  requirements and benefits
• Overview of the CareSource Dental Handbook

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Restored Adult Dental Benefits

• Adult dental benefits restored effective July 1,
  2008
• Restoration of the Medicaid adult dental benefits
  - applies to all Ohio Medicaid Covered that was
  in place until December 31, 2005.

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Restored Adult Dental Benefits

• D2933 Prefab Stainless Steel Crown
• D2952 Post Core Cast Crown
• D3320 Root Canal Therapy bicuspids
• D3330 Root Canal Therapy molars
• (Note Root canals require PA if 3 or more root
  canal procedures are scheduled within 6 months).
• D3351 Apexification/recalcification initial
  visit
• D3352 Apexification/recalcification interim
  visit
• D3353 Apexification/recalcalcification final
  visit
• D3410 Apicoectomy/Periradicular Surgery Anterior
  

• D0321 Other TMJ Films
• D1510 Space Maintainer Fixed
• Unilateral
• D1515 Fixed Bilateral Space
• Maintainer
• D1520 Space Maintainer Removable
• Unilateral
• D1525 Space Maintainer Removable
• Bilateral
• D2752 Crown Porcelain w Noble
• Metal
• D2930 Prefab Stainless Steel Crown
• Primary
• D2931 Prefab Stainless Steel Crown
• Perm.

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Restored Adult Dental Benefits

• D4210 Gingivectomy/Plasty Per Quad
• D7220 Impact Tooth Removal Soft Tissue
• D7230 Impact Tooth Removal Partial Bony
• D7240 Impact Tooth Removal Comp Bony
• D7241 Impact Tooth Removal Bony w Comp
• D7250 Tooth Root Removal
• D7270 Tooth Reimplantation
• D7280 Surgical Access Unerupted Tooth
• D7310 Alveoplasty w Extraction
• D7320 Alveoplasty wo Extraction

D7471 Removal Exostosis Any Site D7671
Alveolus Open Reduction D7899 TMJ Unspecified
Therapy D7960 Frenulectomy/Frenulotomy D7970
Excision Hyperplastic Tissue D8210 Orthodontic
Removable Appliance Treatment
D8220 Fixed Appliance Therapy Habit Y7255
Remove Supernumary Tooth
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Dental Provider Communication

• Mailed in mid July
• Outlined Medicaid restored adult dental benefits
• Defined CareSource prior authorization
  requirements
• Introduced the revised CareSource Dental Handbook
• Defined upcoming changes to the process for
  Orthodontia management and billing

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The following services require prior authorization

• D0321 Other TMJ Films
• D2752 Crown Porcelain w Noble Metal
• D2952 Post Core Cast Crown
• D3320 Root Canal Therapy bicuspids
• D3330 Root Canal Therapy molars
• Note Root Canals require PA if 3 or more root
  canal procedures are scheduled within 6 months.

• D3352 Apexification/ recalcificaiton interim
  visit
• D4210 Gingivectomy/Plasty Per Quad
• D7240 Impact Tooth Removal Comp Bony
• D7241 Impact Tooth Removal Bony w Comp
• D7250 Tooth Root Removal
• D7280 Surgical Access Unerupted Tooth

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The following services require prior authorization

• D7471 Removal Exostosis Any Site
• D7899 TMJ Unspecified Therapy
• D7960 Frenulectomy/ Frenulotomy
• D7970 Excision Hyperplastic Tissue
• D8210 Orthodontic Removable Appliance Tx
• D8220 Fixed Appliance Therapy Habit
• Y7255 Remove Supernumary Tooth

• D5110 Complete Upper Denture - Maxillary
• D5210 Complete Lower Denture - Mandibular
• D5211 Maxillary Upper Partial Denture - Resin
  Base
• D5212 Mandibular Lower Partial Denture - Resin
  Base
• D5213 Maxillary Upper Denture Partial Cast
  metal
• D5214 Mandibular Lower Denture Partial - Cast
  metal

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Orthodontia

• As required by Ohio Administrative Code, coverage
  of comprehensive orthodontics is limited to the
  most severe handicapping orthodontic conditions.
• Comprehensive orthodontics should be considered
  only after eruption of permanent centrals,
  laterals, first molars and first premolars. 
  Exceptions can be made in the case of severe
  maxillary and / or mandibular growth
  abnormalities.
• Coverage is limited to patients younger than 21.
• Only one course of comprehensive orthodontic
  treatment per person, per lifetime is covered and
  is capped at a total dollar amount.

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Orthodontia Changes

• Current CareSource orthodontia review policy will
  be in effect until October 1, 2008.
• Beginning October 1, a two-step review process
  will be required. 
• Please refer to pages 16-19 of the CareSource
  Dental Handbook for detailed information.

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Orthodontia Changes

• Step 1 Evaluation for Orthodontia Referral
• The referring dentist or orthodontist must submit
  a request for orthodontic workup.
• Required Documentation
• Orthodontic predetermination form
• A diagnostic complete set of radiographs OR a
  diagnostic panoramic radiograph OR photos showing
  the patient's bite and occlusal view
• Any other supporting documentation
• If it is determined that the patients condition
  meets the established CareSource/ODJFS guidelines
  as having the most severe handicapping
  orthodontic condition, an authorization for a
  comprehensive orthodontic workup will be given.

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Orthodontia Changes

• Step 2 Orthodontic Workup
• If, after the orthodontic workup, the
  orthodontist believes the member may meet the
  CareSource/ODJFS guidelines as having the most
  severe handicapping orthodontic condition, the
  orthodontist must submit a request for
  comprehensive orthodontic treatment.
• Required Documentation
• A diagnostic complete set of radiographs OR a
  diagnostic panoramic radiograph
• Properly trimmed study or computer models
  (preferred)
• Cephalometric films (D0340)-no tracings
• Lateral and frontal photographs of the patient
  with lips together
• Any other supporting documentation

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Orthodontia Changes

• Step 2 Orthodontic Workup (cont.)

• If the request for comprehensive orthodontic
  treatment is approved, an authorization will be
  sent to the requesting provider which will
  provide authorization for the entire course of
  treatment (as long as the patient remains an
  eligible CareSource member.

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Orthodontia Changes

• Beginning October 1, 2008 orthodontia
  reimbursement for maintenance services will have
  the following changes
• Monthly billing cycle (D8030 Monthly Orthodontic
  Treatment) instead of quarterly for new starts
  only. 
• For ease of billing, orthodontists can continue
  quarterly claims submission for new patients by
  submitting 3 of the D8030 monthly charges if the
  patient was enrolled and actively being treated
  during that quarter.
• The quarterly billing cycle (D8670 Quarterly
  Orthodontic Treatment) should be continued for
  existing patients until their treatment is
  concluded.

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Reimbursement
Per Ohio Administrative Code 51013-1-60 Medicaid
reimbursement Payment for a covered
service constitutes payment-in-full and may not
be construed as a partial payment when the
reimbursement amount is less than the providers
charge. The provider may not collect and/or bill
the consumer for any difference between the
payment and the providers charge or request the
consumer to share in the cost through a
deductible, coinsurance, co-payment or other
similar charge.
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Reimbursement

• CareSource absorbs any member co-payments.
• The cost of analgesic and local anesthetic agents
  is included in the fees associated with covered
  dental services and is not reimbursed separately.

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Dental Handbook

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CareSource Dental Handbook

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CareSource Dental Handbook

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CareSource Dental Handbook

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Questions