A Presentation for the Old Dominion Dental Society

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A New Day For Oral Health In Virginia
Orthodontic Provider Education Seminar July 30,
2008

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Agenda

• Welcome and Introductions
• Overview of Orthodontic Services and Benefits
• Q A
• Training Evaluation

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Training Objectives

• Clarify and address orthodontic issues related
  to
• Eligibility
• Coverage
• Authorizations
• Continuation of Care
• Billing

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Coverage
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Who is Eligible for Ortho Coverage?

• SFC enrollees age 20 and under may qualify for
  orthodontic care under the program.
• Members must have a severe, dysfunctional,
  handicapping malocclusion.
• Members whose molars and bicuspids are in good
  occlusion seldom qualify.
• Crowding alone is not usually dysfunctional in
  spite of the aesthetic considerations.
• Members should present with a fully erupted set
  of permanent teeth.
• At least ½ to ¾ of the clinical crown should be
  exposed, unless the tooth is impacted or
  congenitally missing.

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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.
• When using the IVR to verify eligibility, the
  system will inform the Provider if the member is
  eligible or not.  At that point, the provider can
  select the following options from the call menu
• For benefit information or eligibility
  discrepancies obtained in this system press or
  say 4
• 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 who lose eligibility prior
  to the completion of their orthodontic treatment
  will be covered for the duration of the
  orthodontic treatment if she/he was eligible on
  the date of banding.

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Comprehensive Orthodontic Treatment
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Comprehensive Orthodontic Services

• All comprehensive orthodontic services require
  prior authorization by a Doral Dental Consultant.
• An ADA claim form, trimmed diagnostic study
  models with waxbites or an OrthoCadTM electronic
  equivalent, panoramic or periapical radiographs
  and a treatment plan must be submitted with a
  request for prior authorization of services.

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Orthodontic Review Process

• Requests for orthodontic coverage are evaluated
  using
• Medical necessity/handicapping criteria as a
  first level review to determine coverage as
  applied to the permanent dentition.
• If the requested treatment does not meet any of
  the listed criteria, Doral evaluates the case
  based on the Salzmann Malocclusion Severity
  Assessment. The member must score a minimum of
  25 points to quality for coverage.
• Additional documentation of medical necessity
  will be requested for cases not meeting the
  handicapping criteria or Salzmann Malocclusion
  Severity Assessment. This documentation must be
  submitted within 30 business days from the
  determination date and must support impaired
  function in one of the following areas
• Speech disorder Documented by a physician or
  speech therapist
• Eating disorder Documented by a physician
• Emotional mental distress to impair school
  participation Documented by a teacher, a
  counselor, or a school psychologist

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Orthodontic Review Process
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Services Included in Comprehensive Orthodontics

• The maximum case payment for orthodontic
  treatment is 1 initial payment (D8080) and 3
  quarterly periodic billed orthodontic treatments
  (D8670)
• The initial payment for orthodontics (D8080)
  includes
• Pre-orthodontic visit
• Radiographs
• Treatment Plan
• Records
• Diagnostic models
• Initial banding
• Debanding
• 1 Set of retainers
• 12 Retainer adjustments
• Providers must submit claims for 3 quarterly
  payments (D8670). Claims must be submitted at
  least 90 days apart.
• Payment for up to one set of lost/non-repairable
  retainers may be considered on a medically
  necessary basis.
• Members may not be billed for broken, repaired,
  or replacement of brackets or wires.

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Other Orthodontic Treatment Services
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Phase I and Phase II Orthodontia

• In addition to covering Comprehensive orthodontic
  treatment (D8080), the SFC program also covers
  Limited orthodontic treatment
• D8020 Limited orthodontic treatment of the
  transitional dentition
• D8030 Limited orthodontic treatment of the
  adolescent dentition
• D8040 Limited orthodontic treatment of the adult
  dentition
• Limited orthodontic treatment may be approved
  when it is definitive treatment. This means that
  no other orthodontic treatment will be necessary.
• Limited orthodontic treatment that is not
  definitive is covered as part of a comprehensive
  treatment plan.
• Phase I and Phase II orthodontia are not covered
  as two separately reimbursable services.

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Interceptive Orthodontic Services

• Interceptive treatment is not covered by the SFC
  program.
• The placement of palatal expanders and other
  orthodontic appliances are not separately
  reimbursable services under the program benefits.
  

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Removal of Appliances

• The fee for Comprehensive orthodontic services
  includes the removal of appliances and is not a
  separately reimbursable service for the provider
  who initially banded the case.
• Removal of appliances by a provider other than
  the provider who placed the retainer is
  considered on a case by case basis.
• Providers should submit a request with code D8999
  along with a description of the service
  performed, narrative of medical need, and a photo
  of the appliances to be removed.

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Continuation of Orthodontic Treatment
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Requests for Continuation of Care
Transition from another SFC Provider

• Requests for continuation of care must include
• A completed Orthodontic Continuation of Care
  Form.
• A completed ADA claim form listing the services
  to be rendered.
• A copy of the members prior approval, including
• Total approved case fee
• Banding fee
• Orthodontic treatment fees

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Requests for Continuation of Care (cont.)
Transition from commercial insurance or self pay

• Requests for continuation of care must include
• A completed Orthodontic Continuation of Care
  Form.
• A completed ADA claim form listing the services
  to be rendered.
• A copy of the members prior approval obtainable
  from the commercial insurance or original
  treating orthodontist, including
• Total approved case fee
• Banding fee
• Orthodontic treatment fees
• The original diagnostic models, and radiographs
  if available, banding date, and a detailed
  payment history

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Requests for Continuation of Care (cont.)

• In cases where the member has exhausted their
  comprehensive orthodontic benefit limit, the
  request for continuation of care is reviewed on a
  case by case basis to determine if additional
  coverage will be allowed. A fee will be
  determined by Doral based on Medicaid treatment
  guidelines and Medicaid rates.
• If continuing orthodontic care requires a member
  to be re-banded, the continuation of care request
  must be submitted with continuation of care
  documents, a treatment plan and current
  diagnostic models. The case must meet the
  medical necessity criteria or alternate Salzmann
  score criteria or be evaluated on a case by case
  basis in order for a full case rate to be paid.

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Billing for Orthodontic Services
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Ancillary Claim/Treatment Location

• This section of the claim form provides
  additional information to Doral regarding the
  claim.
• Box 39 - Number of Enclosures
• This item is completed whether or not
  radiographs, oral images, or study models are
  submitted with the claim.
• If no enclosures are submitted, enter 00 in each
  of the boxes to verify that nothing has been sent
  and therefore no possible attachments are
  missing.
• Box 41 Date Appliance Placed
• Indicate the date an orthodontic appliance was
  placed.
• This information should also be reported in this
  section for subsequent orthodontic visits.

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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 orthodontic
  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
  last service date the member was eligible.

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Denied Cases Payment for Records

• Payment of records for cases that are denied is
  made automatically.
• There is no need to submit for the records
  payment (Code D8660).
• An internal authorization is issued for the
  payment of the pre-orthodontic visit (code
  D8660), which includes
• Treatment Plan
• Radiographs and/or photos
• Records
• Diagnostic models
• In cases where the member has been approved for
  Comprehensive Orthodontic benefits, and the
  parent/guardian decides not to have the child
  begin treatment at the time of the approval or
  any time in the near future, the provider may
  bill for records to include treatment plan,
  radiographs, models, photos, etc. using D8999 and
  explaining the situation on the claim for
  payment. The reimbursement for these records is
  the same as D8660.

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Billing for Continuation of Care

• For continuing orthodontic care, providers may
  bill for the remaining case rate.
• Reimbursement beyond the remaining case rate may
  be considered on a case by case basis.

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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 NPI
• Changes to Tax ID Number(s)
• Plans to retire or modify level of participation
• 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 your experiences (positive or negative)
  with us.
• Let us know what issues you would like addressed
  in our next session.

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Contact Information

• Doral Smiles For Children Staff
• Cheryl Harris, MSHA
• Project Director
• Toll-Free 866-853-0657
• Direct Line [phone]
• Fax [phone]
• Email cpharris_at_doralusa.com
• Bridget Hengle
• Provider Relations Representative
• Toll-Free 866-853-0657
• Direct Line [phone]
• Fax [phone]
• Email bhengle_at_doralusa.com
• Kristen Gilliam
• Outreach Coordinator
• Toll-Free 866-853-0657
• Direct Line [phone]

• DMAS Smiles For Children Staff
• Sandra Brown, MSW
• Dental Program Manager
• Direct Line [phone]
• Fax [phone]
• Email sandra.brown_at_dmas.virginia.gov
• Lisa Bilik
• Dental Contract Monitor
• Direct Line [phone]
• Fax [phone]
• Email lisa.bilik_at_dmas.virginia.gov
• Dr. Marjorie Chema
• Dental Consultant
• Direct Line [phone]
• Fax [phone]
• Email marjorie.chema_at_dmas.virginia.gov

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Thank You!