A Presentation for the Old Dominion Dental Society

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A New Day For Oral Health In Virginia
Spring 2006 Provider Training Seminars March 27
31, 2006

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Agenda

• Welcome and Introductions
• Program Performance Updates
• Enrollee Eligibility
• Prior Authorizations
• Claims
• Enrollee Outreach
• Provider Resources
• Dorals Provider Website
• 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
• Provide clarification regarding the prior
  authorization process for hospital cases
• Outline the process for requesting authorization
  for orthodontic treatment
• Review claims processes and procedures and
  provide helpful hints for timely reimbursement
• Discuss issues related to enrollee access and
  introduce new enrollee outreach activities
• Provide a brief overview of provider resources
• Encourage greater utilization of the Doral
  provider website

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

• The network has increased from 620 to 773
  individual providers with 1022 practice locations
  (As of February 28, 2006)
• Six counties that previously had no participating
  dentists now have access to dental services
• Amelia
• Brunswick
• Charles City
• Highland
• Madison
• Prince George
• DMAS, Doral, the VDA and the Old Dominion Dental
  Society are continuing to enhance the Smiles For
  Children network

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Fee Schedule Increase May 1, 2006
The 2005 General Assembly approved increased
funding for dental rates effective May 1, 2006.
The Dental Advisory Committee decided to target
endodontic and oral surgery codes as well as
conscious sedation
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Pediatric Dental Utilization

• Preliminary analysis indicates an upward trend in
  the number of children receiving care
• As of July 1, 2005, the percentage of enrolled
  providers who were treating Medicaid patients and
  filing claims was approximately 50. Under the
  Smiles for Children program, this percentage is
  now approximately 75
• Through technology and improved customer service,
  enrollee access to dental providers has increased

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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 and
  not eligible for dental benefits.

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Enrollee Eligibility

• Issue After receiving confirmation of
  eligibility, a provider receives a denial of
  claim. The denial reason indicates Member Not
  Found
• How has the issue been addressed DMAS and Doral
  are now exchanging eligibility information
  weekly. DMAS and Doral are making modifications
  to the eligibility file to ensure data is
  complete and accurate.
• Providers are encouraged to contact Doral if a
  claim is denied inappropriately. If eligibility
  can confirmed, the claim will be reprocessed and
  paid accordingly.

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Tips on Members Eligibility Verification

• It is recommended to verify eligibility in the
  month an appointment is scheduled.
• 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 are eligible through the end
  of the month of their birthday.
• 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

• Pre-payment Review
• Requires proper documentation included with claim
  prior to consideration for payment
• Option of requesting prior authorization if
  desired prior to rendering services

• Prior-Authorization
• Authorization and documentation submitted before
  treatment begins
• Authorization decision provided within 2 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
• Authorization decision provided by Doral within 2
  business days from the date the required
  documentation is received
• Upon approval by Doral, required documentation is
  forwarded to MCO if applicable. Authorization
  decision provided by MCO within 2 business days
  from receipt of information from Doral

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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
  ensuring the hospital receives authorization
  information.

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Orthodontic Review Process
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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 (ANC)
• 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 processed within 30 days if receipt.
• A clean claim is defined as a complete claim that
  does not require any additional information to
  process it.
• Dorals average claims processing turnaround
  time 19.18 Days
• Claims are processed according to processing
  cycle
• Cut-off for claims processing cycle is every
  Tuesday at 4 p.m.
• Processing cycle includes
• 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

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Claims ProcessingRequired 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 and a 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.
• If a member becomes ineligible during treatment
  and before full payment is made, Doral will pay
  the balance for any remaining treatment.
• The maximum payment is 1 initial payment (D8080)
  and 3 quarterly periodic billed orthodontic
  treatments (D8670).

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Claims Processing Calendar
Claim Received Prior to Cut-off
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Claims Processing Calendar
Claim Received After Cut-off
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Tips to Ensure Timely Payment

• 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 provider will face timely
  filing denials (Note This is a change from the
  prior contract.)

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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

• Broken appointments are
• A major concern for DMAS, VDA, ODDS, and Doral
• Recognized as expensive for dentists
• Lead to dentists unwillingness to participate in
  the program
• Information is needed to better track, trend, and
  understand the issue
• Doral will use the information to
• Educate families regarding the importance of
  appointments and compliance with treatment plans
• Dentists can assist by completing the Broken
  Appointments Log and faxing to Dorals Outreach
  Coordinator
• Medicaid Transportation is available for dental
  appointments (contracted through the health
  plans)

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Appointment Reminder

• Mailed to enrollees who have not accessed care
• Postcard mailing campaign
• Alexandria
• Norfolk
• Richmond
• Roanoke
• Targeted Mailing Date 4th Quarter

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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!
• Dentists can access
• Patient Eligibility
• Limited Claims History
• Fax Back Confirmation of eIVR call
• Spanish Call Handling
• With eIVR, information can be obtained instantly
  and easily.

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Enhanced Automated Phone System

• Phone number to access this system
  1-888-912-3456, Option 1
• To access eIVR, providers can login with
• Location ID Number
• Last 4 digits of the location TIN
• Full location TIN and Last Name
• Patients eligibility can be verified on the eIVR
  along with limited claim history (codes D0120,
  D0212, 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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Coming Soon! Beginning Summer 2006, Doral will
enhance its on-line services!
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Electronic Funds Transfer (EFT)

• EFT permits the direct electronic deposit of
  Smiles For Children claim reimbursements into a
  bank account designated by the provider whether
  claims are filed electronically or on paper
• Advantages of EFT include
• No lost checks or Post Office delay.
• Savings of administrative and overhead costs.
• No standing in line at the bank.
• Faster access to funds many banks credit direct
  deposits faster than paper checks
• Easier reconciliation of payments with bank
  statements

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Provider Web-Site Enhancements
Enhanced services will include

• Ability for providers to view status of claims
  and prior authorizations
• Provider information component, including
• On-line newsletter
• Program Information

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Contact Information

• Dorals Smiles For Children Staff
• Cheryl Harris Direct Line [phone]
• Project Director Fax [phone]
• Email cpharris_at_doralusa.com
• Anna Perez Direct Line [phone]
• Provider Relations Representative Fax (804)
  217-8349
• Email amperez_at_doralusa.com
• Kristen Fincher Direct Line [phone]
• Outreach Coordinator Fax [phone]
• Email kmfincher_at_doralusa.com
• DMAS Smiles For Children Staff
• Sandra Brown Direct Line [phone]
• Dental Program Manager Email
  sandra.brown_at_dmas.virginia.gov
• Lisa Bilik Direct Line [phone]
• Dental Contract Monitor Email
  Lisa.Bilik_at_dmas.virginia.gov

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Thank You!