Presentation prepared for:

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Presentation prepared for
Avesis Health Partners Dental Providers Staff
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Who is Avesis?

• Mission Statement
• Building long term partnerships to deliver
  valued, Innovative Healthcare Solutions one
  member at a time.
• Dental, Vision and Hearing Plan Administrator
  working with employer groups and health plans
  nationally
• Over 30 years experience in the dental, vision,
  and hearing insurance industry

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Who is Avesis Dental?

• Dental Networks - over 30,000 dentists in 41
  States
• Experienced Administrator 30 years serving
  corporate and government clients
• Avesis administers Medicaid plans in 3 states and
  Medicare Advantage plans in 11 states

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Avesis is National

• Executive Offices in Baltimore, MD
• Operations located in Phoenix, AZ
• Southeast regional office in Atlanta, GA
• Local representatives located in Pennsylvania

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Avesis Staff Contact Information

• Renee Ruggiero Asst Dir of Health Plan Services
• rruggiero_at_avesis.com (800) 643 1132, ext. 753
• Dale Woodie PA State Program Manager
  dwoodie_at_avesis.com (800) 522 0258, ext. 135
• Kelley Owens Senior Provider Relations Rep
• kowens_at_avesis.com (800) 522 0258, ext. 738
• Provider Services
• ( 855) 536 - 7764

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Avesis Clinical Professionals

• Dr. Fred Sharpe Chief Dental Officer
• Dr. Rick Celko National Dental Director of
  Utilization Management and Clinical Integrity
• Dr. Dan Pituch Avesis PA Medical Director

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Avesis Dental Advisory Boards

• Committee of licensed PA Dentists and Avesis
  staff
• Act in an advisory capacity to Health Partners
  Health Plan and Avesis in all matters pertaining
  to the Health Partners Dental Programs
• Help to ensure quality communications between PA
  provider community, Avesis and Health Partners
  Health Plan
• Forum for providers to submit recommendations and
  feedback regarding the programs and their
  administration

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Cultural Competency

• As a company dedicated to providing clients with
  superior service, Avesis fully recognizes the
  importance of serving Members in a culturally and
  linguistically appropriate manner. We know from
  direct experience that
• Some Members have limited proficiency with the
  English language including some Members whose
  native language is English but who are not fully
  literate.
• Some Members have disabilities and/or cognitive
  impairments that impede their communicating with
  us and using health care services.
• Some Members come from other cultures that view
  health-related behaviors and health care
  differently than the dominant culture.

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Cultural Competency

•  To be culturally competent, Providers shall
• Work with Members so that once Members are
  identified that may have cultural or linguistic
  barriers alternative communication methods can be
  made available.
• Utilize culturally sensitive and appropriate
  educational materials based on the Members race,
  ethnicity and primary language spoken.
• Ensure that resources are available to overcome
  the language barriers and communication barriers
  that exist in the Member population.
• Make certain that you recognize the culturally
  diverse needs of the population.
• Teach staff to value the diversity of both their
  co-workers inside the organization and the
  population served, and to behave accordingly.

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Special Needs

• Avesis works in coordination with the Special
  Needs Unit at the Health Plan to ensure that the
  dental needs of every Member are met.
• If you have a Special Needs Member that requires
  help in securing dental treatment, Avesis can
  assist in coordinating an appropriate referral to
  a dental Provider who is able to meet the
  Members specific needs.

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ELIGIBILITY
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Eligibility

• It is strongly encouraged that you verify
  eligibility for each Members appointment the
  business day prior to rendering services unless
  the next business day is the first day of a new
  month. Please note that verification of benefits
  or eligibility is not a guarantee of payment
  actual payment is based on the terms and
  conditions of the plan in force once the claim is
  received.

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Eligibility

• You may obtain eligibility verification four
  ways
• IVR Please bear in mind that this only provides
  you with information as to whether or not the
  member is eligible on the date of service. It
  does not provide utilization data
• Website This method provides you with
  information as to whether or not the member is
  eligible on the date of service and allows you to
  view the members utilization history.

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Eligibility

• Customer service Customer service is able to
  provide you with both eligibility confirmation as
  well as utilization data.
• Fax You may utilize the form found on the
  following slide for eligibility confirmation.
  This form will provide you with both eligibility
  confirmation and utilization data.

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ELIGIBILITY VERIFICATION FORM
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BENEFITS
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Health Partners Health Plans

• Health Partners has two different programs
• Health Partners the program for Medical
  Assistance Members
• KidzPartners the program for Pennsylvania CHIP
  members
• Benefits vary according to the program in which
  the Member is enrolled.

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General Overview

• Health Partners offers dental care to eligible
  Medical Assistance recipients in the Health
  Partners Health Plan service area.
• KidzPartners is available through a contract with
  the Childrens Health Insurance Program (CHIP) of
  Pennsylvania.
• CHIP is a State and Federally funded program to
  provide health insurance for uninsured children
  from birth until they reach the age of 19.
• In 2007, Pennsylvania CHIP was expanded to offer
  health insurance to children and teens who are
  not eligible for Medical Assistance, regardless
  of family income.
• Enrollment eligibility is evaluated every 12
  months.

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General Benefits

• Covered Services
• Covered services will be paid according to the
  plan fee schedule
• Non-Covered Services
• Non-Covered Services may be the responsibility of
  the member
• In order to be responsible for payment of non
  covered services, Member must be notified of
  financial responsibility prior to services being
  rendered and the provider must obtain written
  verification of this notification.

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Non-Covered Services Disclosure Form
Providers must obtain a written indication from
Avesis that any proposed services are truly
non-covered service for the Member in question
prior to collecting a fee from the Member.
Member pays 80 of Providers Usual and
Customary Fees
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General Benefits

• Program Exception Process
• A program exception occurs when a provider
  contacts Avesis requesting services that are
  non-covered for medical necessity
• Benefits are either exhausted or not a covered
  benefit
• Requests will be reviewed by Utilization
  Management and a decision will be made with in
  two (2) business days.
• Emergency Services
• Members seeking emergency services may need to be
  referred back to Health Partners for medical
  benefits

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Benefit Changes Effective 2013

• There were changes to KidzPartners effective
  January 1, 2013.
• Members enrolled in KidzPartners will no longer
  have access to an expanded dental benefit. This
  expanded dental benefit (EDB) was only available
  for calendar year 2012. The annual maximum for
  all services is 1500.00.
• The orthodontic benefits will no longer be
  reimbursed at a case rate. Beginning with new
  cases banded 1/1/2013 and after, Avesis will be
  paying based upon the previous process of an
  initial banding fee followed by quarterly
  payments. All newly approved and billed
  orthodontic cases for 2013 will be reimbursed
  with a banding fee, up to seven quarterly fees
  and retention. This reimbursement will mirror
  how you are currently being reimbursed through
  the Health Partners Medicaid benefits.

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Benefit Limits

• Effective April 1, 2012, Health Partners adult
  members (age 21 and older) experienced a change
  to their dental benefit that limits the following
  dental services
• Periodic oral evaluations (D0120)
• Prophylaxis, adult (D1110)
• Dentures, both complete and partial (D5110,
  D5120, D5130, D5140, D5211, D5212, D5213, D5214)
• Services provided beyond a Members benefit
  limits are not covered unless a BLE is requested
  and approved by Avesis.

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Benefit Limits

• The Benefit Limits are as listed below
• Periodic oral evaluations (D0120) will be limited
  to one (1) per 180 days per adult Member. NOTE
  Providers will not be paid for a periodic oral
  evaluation (D0120) and a comprehensive oral
  evaluation (D0150) within the same 180 day time
  period.
• Prophylaxis, adult (D1110) will be limited to one
  (1) per 180 days per adult Member.
• Dentures will be limited to one per upper arch,
  full or partial, regardless of procedure code
  (D5110, D5130, D5211, D5213) and one per lower
  arch, full or partial, regardless of procedure
  code (D5120, D5140, D5212, D5214), per lifetime.
  Avesis will review claim payment history for
  dates of service on and after March 1, 2004 to
  determine if the Member previously received a
  denture for the arch.

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Benefit Limits

• Effective April 1, 2012, Health Partners adult
  members (age 21 and older) were eligible for the
  following services only if Avesis approves a BLE
  request
• Crowns and adjunctive services (D2710, D2721,
  D2740, D2751, D2791, D2910, D2915, D2920, D2952,
  D2954, D2980)
• Periodontic services (D4210, D4341, D4355, D4910)
• Endodontic services (D3310, D3320, D3330, D3410,
  D3421, D3425, D3426)

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Benefit Limits

• NOTE The dental benefit changes do not apply to
  children under 21 years of age or to adults who
  reside in a nursing facility, an intermediate
  care facility for persons with mental retardation
  (ICF/MR) or an intermediate care facility for
  persons with other related conditions (ICF/ORC).

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EPSDT Services

• The Early and Periodic Screening, Diagnostic, and
  Treatment (EPSDT) programis Medical Assistance's
  comprehensive and preventive child health program
  for individuals under the age of 21.
• EPSDT includes periodic screening, vision,
  dental, and hearing services.

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EPSDT Services

• If a Provider is unable to conduct the necessary
  EPSDT screens for Members under age 21, the
  Provider is responsible for making a referral to
  another Participating Provider to ensure the
  Member has the necessary EPSDT screening
  performed.
• All relevant medical information, including the
  results of the EPSDT screening, are to be
  incorporated into the Members primary medical
  record.

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EPSDT Services

• Based upon the requirements of the EPSDT program,
  each Avesis provider office is required to
  maintain and document the Member recall policies
  and procedures for all Health Partners and
  KidzPartners Members.
• Additional information on the EPSDT program can
  be found at www.cms.hhs.gov/Medicaid/epsdt.

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CLAIMS
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CLAIM SUBMISSION

• Claims may be submitted one of three ways
• Through your practice management software using a
  clearinghouse
• On an ADA claim form - please submit to the
  following address
• Avesis Dental Claims
• PO Box 7777
• Phoenix, AZ 85011 7777
• Utilizing our website at www.avesis.com

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CLAIMS FOLLOW UP

• Providers receive remittance advices detailing
  claims both paid and denied. If you believe you
  have not received status on a claim, you may
  check the status of submitted claims two ways
• You may check claim status on the Avesis website
  at www.avesis.com.
• You may contact our provider services department
  at (855) 536 - 7764 to check claim status.

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CORRECTED CLAIMS

• Submission
• If you are missing information (i.e. tooth number
  or quadrant number) or you have submitted
  incorrect information (wrong code, wrong tooth
  number, etc) you may edit the claim on the Avesis
  website.
• If you wish to submit a corrected claim on an ADA
  claim form you will need to do the following
• Write corrected claim on the top of the ADA claim
  form in blue or black ink. The scanner does not
  read red ink
• Please do not highlight notes on the claim in
  blue or green highlighter. The scanner reads
  these colors as black so what ever they highlight
  is blacked out.

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CLAIMS PAYMENT

• Electronic Funds Transfer available for all
  claims submissions or resubmissions
• Check runs WEEKLY
• EFT payments deposited weekly
• CLEAN CLAIMS processed and adjudicated within 15
  business days
• CPS transactions completed weekly

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Electronic Funds Transfer Agreement
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Card Payment Services (CPS)

• Your office may have received a communication
  concerning the partnership between Avesis and
  Card Payment Services (CPS), to transmit future
  claims payment transactions via the MasterCard
  network.
• Frequently Asked Questions are available in the
  Provider Newsletter and upon request. Please let
  your Provider Services Representative know if you
  have any additional questions.

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PRIOR AUTHORIZATION

• PRE-TREATMENT ESTIMATES
• BENEFIT EXCEPTIONS

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Avesis Pre-Treatment Estimate/Prior Approval

• Services requiring prior approval are listed in
  detail in the provider manual
• Providers may submit both pre-treatment estimates
  and requests for benefit exceptions on an ADA
  claim form to our Phoenix address or via the
  Avesis website at www.avesis.com with all
  pertinent clinical information to accompany the
  request.

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Avesis Pre-Treatment Estimate/Prior Approval

• Avesis accepts electronic attachments via the
  Avesis web portal.
• Prior authorization and benefit exception
  requests are processed within 2 business days of
  the receipt of all required information.
• Both the provider and Member will receive a
  written notice of the approval or denial of the
  request. Denials of service will contain an
  explanation as to the reason for the denial.

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Requesting a Benefit Limit Exception

• Avesis will grant benefit limit exceptions to the
  dental benefits when one of the following
  criteria are met
• Avesis determines the Member has a serious
  chronic systemic illness or other serious health
  condition and denial of the exception will
  jeopardize the life of the Member.
• Avesis determines the Member has a serious
  chronic systemic illness or other serious health
  condition and denial of the exception will result
  in the rapid, serious deterioration of the health
  of the recipient.

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Requesting a Benefit Limit Exception

• Continued -
• Avesis determines that granting a specific
  exception is a cost effective alternative.
• Avesis determines that granting an exception is
  necessary in order to comply with Federal law.

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Requesting a Benefit Limit Exception

• In order to request a dental BLE, dentists must
  submit the following information to Avesis
• An American Dental Association (ADA) claim form
  completed in its entirety. Providers must include
  their NPI number on the claim form. Failure to do
  so will result in your BLE request being returned
  to the requesting office.
• A completed Avesis Dental BLE request form.

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Requesting a Benefit Limit Exception

• Providers may require a BLE prospectively (prior
  to services being rendered) or retrospectively
  (after services are rendered).
• Retrospective BLE requests must be submitted no
  later than 60 days from the date Avesis denies
  the claim because the service was originally over
  the benefit limit.
• Retrospective BLE requests received on or after
  the 61st day from the date of the claim rejection
  will be denied.
•  

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Requesting a Benefit Limit Exception

• Avesis will respond to prospective BLE requests
  within 21 days after the request is received.
• Avesis will respond to a retrospective BLE
  request within 30 days after the request is
  received.
• Both the provider and Member will receive a
  written notice of the approval or denial of the
  dental BLE request.

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CHART REVIEWS
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Avesis Office Visits

• Avesis conducts office reviews for our dental
  provider networks
• Your office will be contacted in order for Avesis
  to schedule a time to come out and perform the
  onsite visit
• In addition to a facility walk through, providers
  will be furnished a list of charts prior to the
  visit to have available for review
• After the visit, your office will be sent a
  letter regarding the findings of our review

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PROVIDER SERVICES
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Services to Providers

• Avesis is primary for Provider Services
• Toll free phones staffed by experienced and
  knowledgeable representatives from 7am 7pm EST
• State and National professionals involved in
  professional decisions regarding care and
  referrals

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Services to Providers (Cont.)

• Local Avesis representative
• Regional meetings and training sessions scheduled
  for providers
• Quarterly Provider Newsletters
• On-site assistance in your office when available
• Peer to peer interaction for Providers

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Other Avenues for Assistance

• Schedule a conference call
• Schedule a web demo
• Schedule an onsite visit

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Committed to Technology

• 24/7 Access to information
• Web Based
• Eligibility verification
• Claim submission with real time claims processing
• Claim status and editing
• Remittance advice information
• Pre-treatment Estimate
• Interactive Voice Response (IVR)
• Eligibility
• Benefits

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Committed to Technology

• Avesis offers online assistance with website
  navigation. Providers may access tutorials that
  show how to create an account, confirm
  eligibility and submit claims on the Avesis
  website at http//www.avesis.com/provider_videos.h
  tml
• Providers may also contact Avesis for a web
  demonstration and training session by calling
  (855) 536 7764.

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THANK YOU

• Thank you for your time attention.
• We at Avesis look forward to
• working with you and your team.