An educational presentation
This presentation is the property of its rightful owner.
Sponsored Links
1 / 38

An Educational Presentation PowerPoint PPT Presentation


  • 102 Views
  • Uploaded on
  • Presentation posted in: General

An Educational Presentation. Prepared For:. Avesis/Wellcare of Kentucky Dental Providers & Staff. Presented by: Avesis. September 2012. Mission Statement. Building long term partnerships to deliver valued, innovative healthcare solutions… one member at a time.

Download Presentation

An Educational Presentation

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


An educational presentation

An Educational Presentation

Prepared For:

Avesis/Wellcare of Kentucky Dental Providers & Staff

Presented by: Avesis

September 2012


Mission statement

Mission Statement

Building long term partnerships to deliver valued, innovative healthcare solutions… one member at a time.


Who we are

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

Covering over 4.5 million members throughout the country

Who We Are


Avesis dental

Avesis Dental

  • Dental Networks

    • Over 30,000 dentists in 41 States

  • Experienced Administrator

    • 30 years serving corporate and government clients

  • Avesis administers Medicaid dental plans in 4 states and Medicare Advantage dental plans in 11 states


Avesis is national

Avesis is National

  • Executive Offices in Baltimore, MD

  • Operations located in Phoenix, AZ

  • Southeast regional office in Atlanta, GA


An educational presentation

Points of Contact

  • Renee RuggieroAssistant Director of Health Plan [email protected](800) 522-0258 x753

  • Emori CampbellDental Provider [email protected](800) 522-0258 x178

  • Carolyn WrightUtilization [email protected](800) 522-0258 x294


An educational presentation

Points of Contact

  • Robin MaysManager, Dental Provider [email protected](800) 522-0258 x136

  • Angela BridgesProvider Contracting [email protected](800) 522-0258 x156

  • General Provider Inquiries(855) 214-6776


An educational presentation

Clinical Professionals

  • Dr. Fred SharpeChief Dental [email protected]

  • Dr. Rick CelkoRegional Dental [email protected]

  • Dr. Terrence PooleAvesis KY/OH Dental [email protected]


Avesis dental advisory board

Avesis Dental Advisory Board

  • Committee of Kentucky licensed Dentists and Avesis staff

  • Acts in an advisory capacity to Wellcare of Kentucky and Avesis in all matters pertaining to the Avesis/Wellcare of Kentucky Dental Programs


Avesis dental advisory board1

Avesis Dental Advisory Board

  • Help to ensure quality communications between Kentucky provider community, Avesis, and Wellcare of Kentucky

  • Forum for providers to submit recommendations and feedback regarding the programs and their administration


Eligibility

Eligibility


Eligibility1

Eligibility

  • It is strongly encouraged that you verify eligibility for each Member’s 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.


Eligibility2

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 allow you to view the members utilization history. (www.Avesis.com or check the state website https://sso.kymmis.com)

Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data. You may call 855.214.6776 to reach the Customer service department.

Fax – You may utilize the form found of the following slide for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.


Fax eligibility verification

Fax Eligibility Verification


Benefits

Benefits


An educational presentation

Benefits Overview

  • 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 if and only if the Member is notified of and agrees to financial responsibility prior to services being rendered


An educational presentation

Benefits Overview

  • There are two Medicaid programs under Wellcare of Kentucky:

    • Global Choices

    • Family Choice

  • Benefits for children (Members ages 20 and under) are the same in each of the plans

  • Benefits for adults (Members ages 21 and over) vary according to the program in which the Member is enrolled.


An educational presentation

The Global Choices Program

Global Choices is the benefit plan for most Kentucky Medicaid members. This plan covers basic medical and dental services. There are no co-pays for any dental services for Wellcare of Kentucky members enrolled in Global choices. Some service limits can be increased if the service is medically necessary (requires prior approval).


An educational presentation

Benefits for Global Choices

  • Global Choices benefits include but are not limited to:

    • Children under 21:

      • 2 cleanings per 12-month period

      • 1 set of x-rays per 12-month period

      • Extractions and fillings

      • Other dental services are available

    • Adults 21 and over:

      • 1 cleaning per 12-month period

      • Limited to one dental visit per month

      • 1 set of x-rays per 12-month period

      • Extractions and fillings


An educational presentation

The Family Choices Program

Family Choices is the Kentucky Medicaid benefit plan for most children. This plan covers basic medical and dental services. Kentucky Children’s Health Insurance Program (KCHIP) is part of the Family Choices Plan. This is not a complete list of services. Some benefit limits can be increased if the service is medically necessary (requires prior approval).


An educational presentation

Benefits for Family Choices

  • Family Choices benefits include but are not limited to:

    • Children under 21:

      • 2 cleanings per 12-month period

      • 1 set of x-rays per 12-month period

      • Extractions and fillings

      • Other dental services are available


General benefits

General Benefits

  • Benefit Exception/EPSDT Process

    • Benefit 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 Wellcare of Kentucky for medical benefits


  • Non covered services disclosure form

    Non-Covered Services Disclosure Form

    This form is for your protection and the Member pays Usual and Customary Fees


    Claims

    Claims


    An educational presentation

    Claim Submission

    Claims may be submitted one of three ways:

    • Through your practice management software using a clearinghouse

      • The Avesis payer identification number is 86098

  • On an ADA claim form - please submit to the following address:

    Avesis Dental ClaimsPO Box 7777Phoenix, AZ 85011 – 7777

  • Utilizing our website at www.avesis.com


  • Claims follow up

    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) 214-6776 to check claim status


    Corrected claims

    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 regardless of the method of submission.

    • 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


    Avesis claims payment

    Avesis Claims Payment

    • Check runs weekly

    • CLEAN CLAIMS processed and adjudicated within 15 business days

    • Electronic Funds Transfer available for all claims submissions or resubmissions

    • EFT payments deposited weekly


    Electronic funds transfer agreement

    Electronic Funds Transfer Agreement


    Prior authorization

    Prior Authorization

    Pre-treatment Estimates & Benefit Exceptions


    Avesis prior approval requirements

    Avesis Prior Approval Requirements

    • Services requiring prior approval are listed in detail in the provider manual and on the covered benefits schedule.

    • Providers may submit pre-treatment estimates on an ADA claim form to our Phoenix address or via the Avesis website at www.avesis.com.

    • Avesis accepts electronic attachments via the Avesis web portal.


    Chart reviews

    Chart Reviews


    Avesis office visits

    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

    • 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


    Provider services

    Provider Services


    Services to providers

    Services to Providers

    • Avesis is primary for Member and Provider Services

    • Toll free phones staffed by experienced and knowledgeable representatives from 7am – 7pm EST at 855-214-6776.

    • State and National professionals involved in professional decisions regarding care and referrals

    • 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


    Additional assistance

    Additional Assistance

    • Schedule a conference call

    • Schedule a web demo

    • Schedule an onsite visit


    Committed to technology

    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


    Thank you for your time questions

    Thank You For Your TimeQuestions?

    We at Avesis look forward to working with you and your team.


  • Login