A Presentation for the Old Dominion Dental Society

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A New Day For Oral Health In Virginia
Tooth Talk December 12, 2007

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Smiles For Children Program An Overview
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Whos Eligible and How to Apply?

• To participate in Smiles For Children (SFC),
  recipients must first be eligible for Medicaid,
  FAMIS or FAMIS Plus.
• Once eligible, recipients are automatically
  enrolled in the SFC program and receive a Member
  Handbook.
• Recipients do not receive a SFC ID card.
  Recipients may use
• Commonwealth of Virginia (blue and white) plastic
  identification
• MCO identification card
• For questions regarding Medicaid eligibility,
  recipients should
• Visit their local Department of Social Services
• http//www.dss.virginia.gov/
• For questions regarding FAMIS or FAMIS Plus
  eligibility, recipients should
• Go online and visit www.famis.org or
• Call 1-866-87FAMIS (1-866-873-2647)

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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 be
  eligible for dental benefits.

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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, D0274, 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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Enrollee Eligibility FAMIS MOMS

• FAMIS MOMS receive comprehensive health care
  benefits during pregnancy and for two months
  following the end of pregnancy-this includes SFC
  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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Benefits For Enrollees Under Age 21

• SFC provides comprehensive dental benefits for
  enrollees under the age of 21
• Diagnostic
• Preventive
• Restorative
• Endodontics
• Periodontics
• Prosthodontics Removable
• Prosthodontics Fixed
• Oral Surgery
• Orthodontics
• Adjunctive General
• A full explanation of benefits can be found in
  the Office Reference Manual, Exhibit A.

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Benefits For Enrollees Age 21 and Older

• Coverage for adults, age 21 or older, is limited
  to medically necessary oral surgery and
  associated diagnostic services.
• Diagnostic services include the oral examination
  and selected radiographs needed to assess the
  oral health, diagnose oral pathology, and develop
  an adequate treatment plan.
• Extractions for adults must be medically
  necessary and be complicating the patients
  general health as documented by the dentist or
  medical provider
• Severe periodontal infection which causes acute
  pain, loss of appetite or weight due to pain or
  infection
• Exacerbates a medical condition/medical
  management such as diabetes, heart valve condition

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Benefits For Enrollees Age 21 and Older

• Services for adults require Prepayment Review
• Services requiring prepayment review, require
  that proper documentation be submitted with the
  claim following treatment in order for the claim
  to be considered for reimbursement.
• For all services that require Prepayment Review,
  Providers have the option of requesting prior
  authorization
• Services requiring prior authorization/pre-determi
  nation require that documentation regarding the
  medical necessity of the proposed treatment be
  submitted and authorization from Doral be
  obtained before the services are rendered.
• A full explanation of benefits can be found in
  the Office Reference Manual, Exhibit B.
• Oral surgery procedures not listed in Exhibit B
  may be covered under the members medical
  benefits through the Medicaid, FAMIS, or FAMIS
  Plus fee-for-service or managed care organization
  (MCO) program.

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Office Reference Manual

• Policies and procedures
• Instructions for claims filing
• Benefits and limitations
• Instructions regarding services that require
  prior authorization
• Orthodontia criteria
• Outreach services
• American Academy of Pediatric Dentistry (AAPD)
  dental care guidelines
• Important phone numbers and addresses
• The Office Reference Manual (ORM) is available
  on line
• Go to www.doralusa.com. Click on Providers.
  After logging in, View Documents
• or
• Download a copy from the DMAS website at
  http//www.dmas.virginia.gov

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Provider Web Portal (PWP)

• Meets accessibility standards put forth by the
  ADA (Americans with Disabilities).
• Users can use any browser no longer limited to
  Internet Explorer.
• New improved look for ease of use.
• Easy to read menu.
• Email form for streamlined communication.
• Payment release dates so Providers can easily
  track payment dates.
• Location information displayed for the office
  staff to check accuracy and update the
  information via a contact form.
• Claims and authorization entry still available
  with accurate reporting and tracking information.

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Enrollee Outreach Initiatives
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Broken Appointments

• Broken appointments
• A major concern for DMAS, VDA, ODDS, and Doral
• Recognized as expensive for dentists
• Lead to dentists unwillingness to participate in
  the program
• In December 2005, Doral implemented the Broken
  Appointment Tracking Initiative in order to
  collect data to better track, trend, and
  understand the issue
• Doral uses the information to
• Educate families regarding the importance of
  appointments and compliance with treatment plans

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Broken Appointment Initiative

• Broken Appointment Tracking Log Outcomes
• Over 10,000 broken appointments from SFC
  participating dentists have been received since
  Fall 2006.
• Enhancements to the Broken Appointment Tracking
  Form
• Missed appointment - a missed appointment where
  the member or member representative did not call
  to cancel
• Late Notice Cancellation (LNC) - a missed
  appointment with a cancellation less than 24
  hours prior to the appointment time
• Reason codes - 1) forgot about appointment., 2)
  conflict with schedule, 3) transportation 4)
  illness, 5) other.
• Next Steps
• Broken Appointment Best Practices Questionnaire
• Broken Appointment Focused Survey
• SFC Broken Appointment Pilot Program

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SFC Transportation Complaint Form

• Analyses of data related to broken appointments
  indicate problems with transportation as one
  reason for broken appointments.
• Providers are encouraged to report problems with
  transportation to DMAS. The SFC Transportation
  Complaint Form can now be used to report problems.

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Interpreter Services- Pending Implementation

• Title XIX of the Social Security Act requires
  Medicaid providers to provide non-discriminatory
  services to its clients including those with
  limited English proficiency.
• In order to help providers with this requirement,
  DMAS has implemented a provision for
  reimbursement of interpreter services under the
  SFC program when there is a need and it relates
  to the treatment.
• In order for the SFC dentist to be reimbursed for
  interpreter services performed at the dental
  office, the provider must submit documentation
  (invoice) of the services provided by and paid to
  a professional interpreter. The following
  elements must included in the documentation
• Date(s) of Service
• Patient name and ID number
• Copy of the invoice showing the name, address and
  telephone number of the professional interpreter
  service, the type and length of service, and the
  amount paid
• Mail the SFC Professional Interpreter Service
  Invoice Form along with the above documentation
  to
• Doral Dental
• ATTN Lori Howley
• 12121 N. Corporate Parkway
• Mequon, WI 53092
• An interpreter services resource listing will be
  located on the DMAS website, http//www.dmas.virgi
  nia.gov. A copy of the resource listing will also
  be available upon request.

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How to Locate a Provider
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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
• or
• from the Doral website at
• http//www.doralusa.com

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Doral Dental USA Website

• Open Microsoft Internet Explorer and access
  www.doralusa.com.
• Click on the Find A Provider button to
  continue.

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Find A Provider

• You must provide at least a zip code to perform a
  search.
• Select VA-Smiles For Children from the drop down
  menu.
• Click Find Providers

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Find A Provider Search Results

• Search options allow you to narrow a search by
• Provider Specialty
• Languages Spoken
• Mileage Radius
• Hospital Affiliation

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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 Gilliam
• Outreach Coordinator
• Direct Line [phone]
• Fax [phone]
• Email kfgilliam_at_doralusa.com

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

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Thank You!