A Presentation for the Old Dominion Dental Society

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A New Day For Oral Health In Virginia
Fall 2006 Provider Training Seminars October 2-5,
2006

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Agenda

• Welcome and Introductions
• Program Performance Updates
• Enrollee Eligibility
• Prior Authorizations
• Claims Timely Filing Requirements
• Enrollee Outreach
• National Provider Identifier (NPI)
• Provider Resources
• News and Updates
• Q A
• Training Evaluation

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Training Objectives

• Present updates regarding progress towards
  program goals and the latest changes to the
  program
• Clarify and address issues related to
• Eligibility
• Prior authorizations
• Claims and Timely Filing Requirements
• Present updates regarding enrollee outreach
  activities
• Assist providers in understanding the
  requirements for conducting business with the SFC
  program as it relates to the NPI
• Provide a brief overview of provider resources

4
Program Overview Moving Successfully Toward
the Goals
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225 Additional Dentists Have Signed Up

• The network has increased from 620 to 845
  individual providers with 1292 practice locations
  (As of August 31, 2006).
• DMAS, Doral, the VDA and the Old Dominion Dental
  Society are continuing to enhance the Smiles For
  Children network.
• Following an increase in fees on May 1, 2006
  aimed at Endodontic and Oral Surgery codes, an
  aggressive recruitment initiative targeting
  specialists took place during the 4th Quarter of
  the Smiles For Children 1st contract year.

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Pediatric Dental Utilization (Ages 0-20)
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Eligibility
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Enrollee Eligibility

• Doral uses the 12-digit Medicaid ID number as the
  enrollee ID Number.
• Eligibility may be confirmed using
• Doral website
• By calling 1-888-912-3456
• DMAS MediCall voice response system at
  1-800-884-9730 or 1-800-772-9996.
• If DMAS Medicall voice response system is used,
  providers are cautioned to listen to the entire
  message. Members may be in a waiver program, such
  as the Family Planning Waiver, and may not
  eligible for dental benefits.

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Enrollee Eligibility

• FAMIS MOMS receive comprehensive health care
  benefits during pregnancy and for two months
  following the end of pregnancy-this includes
  Smiles For Children dental benefits if under
  twenty one years of age. Detailed information is
  available at www.famis.org.
• Providers are encouraged to contact Doral to
  verify eligibility prior to rendering services.

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Tips on Members Eligibility Verification

• It is recommended to verify eligibility as close
  to the scheduled appointment as possible.
• When using the website to verify eligibility, it
  is recommended that the verification be
  completed within 3 days prior to the date of
  service.
• Patients who turn 21 lose comprehensive
  childrens benefits on their date of birth and at
  that time are only eligible for limited benefits
  for members over 21.
• Orthodontic patients are covered for the duration
  of the treatment if she/he was eligible on the
  date of banding.

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Prior Authorization
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Minimal Authorization Requirements

• Prior-Authorization
• Authorization and documentation submitted before
  treatment begins.
• Authorization decision provided within 4 business
  days from the date the required documentation is
  received.
• For Hospital Dental services, authorization must
  be provided by Doral and the MCO, if applicable.
  
• Pre-payment Review
• Requires proper documentation included with claim
  prior to consideration for payment (see ORM for
  authorization and documentation required for the
  service).
• If authorization is not required, the option of
  requesting prior authorization is available by
  sending a request to the senior dental director
  for review and approval.

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OR Authorizations

• Process to obtain an OR/SPU authorization
• To ensure timely processing, requests should be
  submitted on an ADA claim form and mailed to
  Doral at least 10 days prior to the date of
  service.
• Clinically emergent requests should be marked as
  such and faxed to 262-834-3575.
• Emergent care is defined as A dental or oral
  condition that requires immediate services for
  relief of symptoms and stabilization of the
  condition such conditions include severe pain
  hemorrhage acute infection traumatic injury to
  the teeth and surrounding tissues or unusual
  swelling of the face and gums.
• Medical necessity should be clearly stated.
• Authorization of any services applicable to D9999
  should be submitted along with the request for
  SPU preauthorization.
• Doral is responsible for the coordination of the
  authorization process with the Managed Care
  Organizations.
• Authorization determination letters for
  non-emergent care are mailed to the providers.
• Authorization determination letters for emergent
  care are faxed to the provider.
• Dentist/Dental Offices are responsible for
  communicating to the hospital all relevant
  authorization information received from Doral.

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Claims
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Four Methods to Submit Claims

• Electronic via Dorals Internet Website
• Electronic via Clearinghouse
• Affiliated Network Services (ANS)
• HIPAA compliant 837D File
• Paper claims
• Any ADA approved claim forms may be used (e.g.
  1994, 2000, 2002-2004)

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Claims Processing

• As a third party administrator, Doral pays claims
  upon receipt of funds from DMAS.
• Contractual guidelines state that clean claims
  are to be adjudicated (processed) within 30 days
  if receipt.
• Dorals average claims processing turnaround time
  is 19.73 Days.
• Cut-off for claims processing cycle is every
  Tuesday at 4 p.m.
• Claims are processed according to the following
  processing cycle
• Adjudication of claim
• Reporting to DMAS
• Approval of funds by DMAS
• Checks are cut upon approval of payment from
  DMAS.
• Checks are mailed upon receipt of funding from
  DMAS.
• Adjudication is defined as Dorals internal
  processing of claims according to contractual
  requirements.

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Time Frame for Claims Adjudication

• Average Number of Claims Adjudicated Per Month
  33,139
• Average Turnaround Time (July 2005 June 2006)
  19.73 Days
• 99.8 of all clean claims adjudicated within 30
  days of receipt of claim
• Performance Standard 90 of clean claims are
  adjudicated within 30 calendar days of receipt of
  claim.
• 100 of all claims adjudicated within 60 days
• Performance Standard 99.5 of all provider
  claims for services are adjudicated within 60
  calendar days.

Performance Goal
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Claims Processing
Required Information

• Most pertinent sections of the ADA form that must
  be completed in full in order to process your
  claims
• Members information
• Name
• Address
• Date of Birth
• Subscriber ID Number
• Record of services provided
• Date of service
• Fee
• Valid procedure code
• Tooth number, tooth surface or quadrant if the
  procedure code requires it
• Treating address
• Treating provider
• Billing entitys information

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Orthodontic Claims

• The start and billing date is defined as the date
  when the bands, brackets, or appliances are
  placed in the members mouth.
• The maximum payment is 1 initial payment (D8080)
  and 3 quarterly periodic billed orthodontic
  treatments (D8670). Payment includes
  Pre-orthodontic visit, radiographs, treatment
  Plan, records, diagnostic models, initial
  banding, debanding, 1 set of retainers, and 12
  months of retainer adjustments.
• If a member becomes ineligible during treatment
  and before full payment is made, Doral will pay
  the balance for any remaining treatment. The
  claim must be submitted using D8999 with the date
  of banding as the date of service.
• For orthodontic cases that are denied, Doral
  generates payment using D8660. This payment
  includes the pre-orthodontic visit, and any
  records.

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Timely Filing Requirement

• The timely filing requirement for the Smiles For
  Children program is 180 calendar days form the
  date of service and receipt of the claim.
• If the original claim was processed and paid and
  an adjustment is requested, the adjusted claim
  must be submitted and received within 12 months
  from the date the original claim was paid.
• When a member has other coverage, the timely
  filing limit begins with the date of payment or
  denial from the primary carrier.
• A claim that is denied for timely filing cannot
  be appealed.

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Tips to Ensure Timely Payment

• Submit claims electronically (52.97 of providers
  are submitting electronically)
• Submit legible and correctly completed ADA claim
  forms
• Alert Doral of any changes (i.e TIN, location,
  etc.)
• Submit claims as soon after date of service as
  possible
• Ensure that claim forms are filled out completely
• When requested, be sure to use the treating
  location not a P.O. Box
• Use the patients name as shown on their ID
  Card/legal name no nicknames
• Claims must be submitted within 180 Days from the
  date of service or the provider will face timely
  filing denials.

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Enrollee Outreach
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Enrollee Access

• Find A Provider A provider search feature on
  the DMAS and Doral websites. A dentist can be
  located within a certain mile radius from any
  given zip code.
• Provider Directory The provider directory is
  posted on the DMAS and Doral websites.
• A Provider Directory was mailed to recipients and
  all new recipients receive a copy. This is the
  first provider directory ever provided to
  Medicaid enrollees.
• eIVR An enhanced automated phone system through
  a single 800 toll-free number. Members can
  verify eligibility and find a dentist through the
  automated system by entering a zip code.
  Services are available in Spanish and English.
• Customer Service Representative Members may also
  speak directly with a customer service
  representative for additional assistance during
  extended customer service hours.

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Broken Appointments

• Doral introduced the Broken Appointment Log at
  the Spring 2006 Provider Training Session held in
  March
• Broken Appointments are defined as those
  appointments that are not rescheduled or
  cancelled in accordance with the providers
  office policies.
• Broken Appointment Log also featured in DMAS
  Spring 2006 Program Update Memo and Dorals
  Smiles For Children Provider Newsletter.
• Dorals Office Reference Manual (ORM) updated to
  include the form.

A copy of the form can be downloaded from the
DMAS website at http//www.dmas.virginia.gov
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Dental Check Up Reminder
Dental Check up Reminder postcards were mailed to
all enrollees with no record of receiving
services from July 1, 2005 April 26, 2006.
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NATIONAL PROVIDER IDENTIFIER(NPI)
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What is the NPI?

• The NPI is a HIPAA standard identifier to be used
  in standard electronic health care transactions.
• It is a unique health care provider identifier
  consisting of 10 numeric positions, which
  identifies providers as part of the U.S health
  care system.
• Does not itself convey information about the
  provider
• Permanent identifier
• Unique identifier

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NPI and Smiles For Children

• The Health Insurance Portability and
  Accountability Act of 1996 (HIPAA) requires all
  participating healthcare providers to obtain and
  use a National Provider Identifier (NPI) in lieu
  of other provider identifiers, such as Medicaid
  ID or Doral Provider ID, for all standard
  transactions
• Claim submissions
• Eligibility inquiries and responses
• Claims status inquiries and responses
• Prior Authorizations
• Referrals
• Remittance advices
• To prepare for the transition to the NPI, Doral
  and DMAS are targeting January 22, 2007 as the
  starting date for using NPIs in transactions from
  providers. Providers should plan to obtain and
  submit your NPI to Doral no later than January
  19, 2007.
• Failure to submit our NPI to Doral will result in
  delay of pertinent information and non-payment of
  your claims. Beginning May 23, 2007, your NPI is
  required to be in Dorals system in order to do
  business with and receive reimbursement for
  services under the Smiles For Children program.

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How do you obtain a NPI?

• The Centers for Medicaid Medicare (CMS) has
  developed the National Plan and Provider
  Enumeration System (NPPES) to assign the unique
  NPI identifier.
• Methods to obtain a NPI include
• Apply on paper (mail)
• Available since 2005- Obtain one now
• Download the paper application
• www.cms.hhs.gov/NationalProvIdentStand/
• Apply via the web (on-line application)
• Available May 23, 2005
• https//NPPES.cms.hhs.gov/NPPES/Welcome.do
• Apply using the Electronic File Interchange
  (EFI)
• Available May 2006

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How to Contact the NPI Enumerator

• Phone
• 1-800-465-3203 (NPI Toll-Free)1-800-692-2326
  (NPI TTY)
• E-mail
• customerservice_at_npienumerator.com
• Mail
• NPI EnumeratorPO Box 6059Fargo, ND 58108-6059

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NPI Implementation Timeline

• Phase I June 2006-January 21, 2007
• Obtain your NPI but do not use it when submitting
  claims and requesting pre-authorization until
  after January 21, 2007.
• Phase II January 22, 2007-May 22, 2007
• Dual use of a Doral Provider ID and NPI (claims
  will be processed utilizing the NPI if indicated
  on the claim)
• Phase III May 23, 2007 forward
• Claims must be submitted with a NPI to be
  processed

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Provider Resources
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Provider Directory

• Contents
• Provider name
• Practice name
• Office address(es)
• Telephone number(s)
• Provider specialty
• Panel status
• Office hours
• Languages spoken
• Any other panel limitations

• Directory may be downloaded from the DMAS website
  at
• http//www.dmas.virginia.gov/dental-home.htm
• or
• from the Doral website at
• http//www.doralusa.com

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Interactive Phone System

• AVAILABLE 24 HOURS A DAY!
• By dialing 1-888-912-3456 and choosing option 1
  providers can access
• Patient Eligibility
• Limited Claims History
• Fax Back Confirmation of eIVR call
• Spanish Call Handling
• Patients eligibility can be verified on the eIVR
  along with limited claim history (codes D0120,
  D0150, D0210, D0272, D274, D0330, D1110, D1120,
  D1201, D1203, D1204, D1205, D1351, D5110, D5120,
  D5130 and D5140)
• Confirmation fax of the eIVR available to
  providers who use the system
• Option to choose Spanish or English

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Keep Doral Updated

• Accurate and up-to-date information is essential
  for appropriate referrals and claims payment.
• Inform Doral of
• Changes to your address, phone and fax numbers
• New practice locations
• Changes to Tax ID Number(s)
• Plans to retire or terminate
• Alert Doral of broken appointments occurring in
  your practice
• Send an application for new providers joining
  your practice at least 30 days prior to the
  effective date and respond to Dorals
  credentialing requests in timely manner
• Share you experiences (positive or negative) with
  us
• Let us know what issues you would like addressed
  in our next session

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NEWS AND UPDATES
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Electronic Funds Transfer (EFT)

• Doral had anticipated a summer roll-out of the
  EFT process, but as we delved into the process we
  learned two things
• EFT would truly be a benefit to providers when an
  electronic remittance would also be available in
  order for providers to appropriately apply
  payments.  In order to be most effective, Doral
  decided it would be best to roll out EFT and
  electronic remittance at the same time.
• Significant system development is required to
  ensure an effective, efficient, error-free
  transition to these electronic processes.
• Doral is currently analyzing the project scope
  and resources. Doral will be working with a
  vendor on this project. At this time, a Fall 2007
  release date is anticipated.

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Provider Web-Site Enhancements
On-line Authorization Status

• Doral can now receive electronic preauthorization
  requests directly on Dorals website or when
  submitted through a clearinghouse.
• The electronic preauthorization request must be
  submitted with the required electronic
  attachments.
• Electronic attachments can be sent to Doral
  Dental using National Electronic Attachment
  (NEA) FastAttach.

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Revised Office Reference Manual

• The Office Reference Manual (ORM) has been
  revised. An updated copy is available on line
• Go to www.doralusa.com. log in to the website
  and click on Documents in the navigation bar on
  the top of the screen.
• or
• Download a copy from the DMAS website at
  http//www.dmas.virginia.gov/dental-home.htm

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Highlight of ORM Revisions

• Added Section 2.07 BROKEN APPOINTMENTS and
  APPENDIX A ATTACHMENT, Broken Appointment Form.
• Revised Section 4.06 FILING LIMITS to clarify
  timely filing requirements.
• Revised EXHIBIT A PAGE 52 to provide
  instructions regarding orthodontic payment for
  members that become ineligible during treatment
  and remain in treatment.
• Revised the ORTHODONTIC CRITERIA INDEX FORM to
  include criterion CR Crowding of 7-8 mm in
  either the maxillary or mandibular arch.
• Revised Section 9 CREDENTIALING to add the
  requirement for a National Provider Identifier
  number as an additional credentialing criterion.
• Added Section 11, Paragraph C., EFFECTIVE
  COMMUNICATION, to clarify expectations regarding
  enrollees with special needs, such as interpreter
  services for persons with communication and
  language barriers.

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Contact Information

• Doral Smiles For Children Staff
• Cheryl Harris
• Project Director
• Direct Line [phone]
• Fax [phone]
• Email cpharris_at_doralusa.com
• Anna Perez
• Provider Relations Representative Direct Line
  [phone]
• Fax [phone]
• Email amperez_at_doralusa.com
• Kristen Fincher
• Outreach Coordinator
• Direct Line [phone]
• Fax [phone]
• Email kmfincher_at_doralusa.com

• DMAS Smiles For Children Staff
• Sandra Brown, MSW
• Dental Manager
• Direct Line [phone]
• Email sandra.brown_at_dmas.virginia.gov
• Lisa Bilik
• Dental Contract Monitor
• Direct Line [phone]
• Email
• Lisa.Bilik_at_dmas.virginia.gov
• Dr. Stephen Riggs, DDS
• Dental Consultant
• Direct Line [phone]
• Email stephen.riggs_at_dmas.virginia.gov

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Thank You!