Agenda

1.

2. 2 Agenda Welcome and Introductions Program Performance Updates Enrollee Eligibility Prior Authorizations Claims & Timely Filing Requirements Enrollee Outreach National Provider Identifier (NPI) Provider Resources News and Updates Q & A Training Evaluation

3. 3 Training Objectives Present updates regarding progress towards program goals and the latest changes to the program Clarify and address issues related to: Eligibility Prior authorizations Claims and Timely Filing Requirements Present updates regarding enrollee outreach activities Assist providers in understanding the requirements for conducting business with the SFC program as it relates to the NPI Provide a brief overview of provider resources

4. 4 Program Overview: Moving Successfully Toward the Goals 

5. 5 225 Additional Dentists Have Signed Up The network has increased from 620 to 845 individual providers with 1292 practice locations (As of August 31, 2006). DMAS, Doral, the VDA and the Old Dominion Dental Society are continuing to enhance the Smiles For Children network. Following an increase in fees on May 1, 2006 aimed at Endodontic and Oral Surgery codes, an aggressive recruitment initiative targeting specialists took place during the 4th Quarter of the Smiles For Children 1st contract year.

6. 6 Pediatric Dental Utilization (Ages 0-20)

7. 7 Eligibility 

8. 8 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 eligible for dental benefits.

9. 9 Enrollee Eligibility FAMIS MOMS receive comprehensive health care benefits during pregnancy and for two months following the end of pregnancy-this includes Smiles For Children 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.

10. 10 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. Patients who turn 21 lose comprehensive children�s benefits on their date of birth and at that time are only eligible for limited benefits for members over 21. Orthodontic patients are covered for the duration of the treatment if she/he was eligible on the date of banding.

11. 11 Prior Authorization

12. 12 Minimal Authorization Requirements Prior-Authorization Authorization and documentation submitted before treatment begins. Authorization decision provided within 4 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. Pre-payment Review Requires proper documentation included with claim prior to consideration for payment (see ORM for authorization and documentation required for the service). If authorization is not required, the option of requesting prior authorization is available by sending a request to the senior dental director for review and approval.

13. 13 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 communicating to the hospital all relevant authorization information received from Doral. Define Emergent - Define Emergent -

14. 14 Claims 

15. 15 Four Methods to Submit Claims Electronic via Doral�s Internet Website Electronic via Clearinghouse Affiliated Network Services (ANS) HIPAA compliant 837D File Paper claims Any ADA approved claim forms may be used (e.g. 1994, 2000, 2002-2004)

16. 16 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 adjudicated (processed) within 30 days if receipt. Doral�s average claims processing turnaround time is 19.73 Days. Cut-off for claims processing cycle is every Tuesday at 4 p.m. Claims are processed according to the following processing cycle: 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. *Adjudication is defined as Doral�s internal processing of claims according to contractual requirements.

17. 17 Time Frame for Claims Adjudication

18. 18 Claims Processing: Required Information Most pertinent sections of the ADA form that must be completed in full in order to process your claims: Member�s information: Name Address Date of Birth Subscriber ID Number Record of services provided: Date of service Fee Valid procedure code Tooth number, tooth surface or quadrant if the procedure code requires it Treating address Treating provider Billing entity�s information

19. 19 Orthodontic Claims The start and billing date is defined as the date when the bands, brackets, or appliances are placed in the member�s mouth. The maximum payment is 1 initial payment (D8080) and 3 quarterly periodic billed orthodontic treatments (D8670). Payment includes: Pre-orthodontic visit, radiographs, treatment Plan, records, diagnostic models, initial banding, debanding, 1 set of retainers, and 12 months of retainer adjustments. If a member becomes ineligible during 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 date of banding as the date of service. For orthodontic cases that are denied, Doral generates payment using D8660. This payment includes the pre-orthodontic visit, and any records.

20. 20 Timely Filing Requirement The timely filing requirement for the Smiles For Children program is 180 calendar days form the date of service and receipt of the claim. If the original claim was processed and paid and an adjustment is requested, the adjusted claim must be submitted and received within 12 months from the date the original claim was paid. When a member has other coverage, the timely filing limit begins with the date of payment or denial from the primary carrier. A claim that is denied for timely filing cannot be appealed.

21. 21 Tips to Ensure Timely Payment Submit claims electronically (52.97% of providers are submitting electronically) 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 patient�s name as shown on their ID Card/legal name � no nicknames Claims must be submitted within 180 Days from the date of service or the provider will face timely filing denials.

22. 22 Enrollee Outreach 

23. 23 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.

24. 24 Broken Appointments Doral introduced the Broken Appointment Log at the Spring 2006 Provider Training Session held in March: Broken Appointments are defined as those appointments that are not rescheduled or cancelled in accordance with the provider�s office policies. Broken Appointment Log also featured in DMAS� Spring 2006 Program Update Memo and Doral�s Smiles For Children Provider Newsletter. Doral�s Office Reference Manual (ORM) updated to include the form.

25. 25 Dental Check Up Reminder

26. 26  NATIONAL PROVIDER IDENTIFIER(NPI)

27. 27 What is the NPI? The NPI is a HIPAA standard identifier to be used in standard electronic health care transactions. It is a unique health care provider identifier consisting of 10 numeric positions, which identifies providers as part of the U.S health care system. Does not itself convey information about the provider Permanent identifier Unique identifier

28. 28 NPI and Smiles For Children

29. 29 How do you obtain a NPI? The Centers for Medicaid & Medicare (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign the unique NPI identifier. Methods to obtain a NPI include: Apply on paper (mail) Available since 2005- Obtain one now Download the paper application www.cms.hhs.gov/NationalProvIdentStand/ Apply via the web (on-line application) Available May 23, 2005 https://NPPES.cms.hhs.gov/NPPES/Welcome.do Apply using the Electronic File Interchange (EFI) Available May 2006

30. 30 How to Contact the NPI Enumerator Phone: 1-800-465-3203 (NPI Toll-Free)1-800-692-2326 (NPI TTY) E-mail: customerservice@npienumerator.com Mail: NPI EnumeratorPO Box 6059Fargo, ND 58108-6059

31. 31 NPI Implementation Timeline Phase I: June 2006-January 21, 2007 Obtain your NPI but do not use it when submitting claims and requesting pre-authorization until after January 21, 2007. Phase II: January 22, 2007-May 22, 2007 Dual use of a Doral Provider ID and NPI (claims will be processed utilizing the NPI if indicated on the claim) Phase III: May 23, 2007 forward Claims must be submitted with a NPI to be processed

32. 32 Provider Resources 

33. 33 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

34. 34 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, 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

35. 35 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 Doral�s 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

36. 36  NEWS AND UPDATES

37. 37 Electronic Funds Transfer (EFT) Doral had anticipated a summer roll-out of the EFT process, but as we delved into the process we learned two things: EFT would truly be a benefit to providers when an electronic remittance would also be available in order for providers to appropriately apply payments.� In order to be most effective, Doral decided it would be best to roll out EFT and electronic remittance at the same time. Significant system development is required to ensure an effective, efficient, error-free transition to these electronic processes. Doral is currently analyzing the project scope and resources. Doral will be working with a vendor on this project. At this time, a Fall 2007 release date is anticipated.

38. 38 Provider Web-Site Enhancements Doral can now receive electronic preauthorization requests directly on Doral�s website or when submitted through a clearinghouse. The electronic preauthorization request must be submitted with the required electronic attachments. Electronic attachments can be sent to Doral Dental using National Electronic Attachment (NEA) FastAttach.

39. 39 Revised Office Reference Manual The Office Reference Manual (ORM) has been revised. An updated copy is available on line: Go to www.doralusa.com. log in to the website and click on �Documents� in the navigation bar on the top of the screen. or Download a copy from the DMAS website at http://www.dmas.virginia.gov/dental-home.htm

40. 40 Highlight of ORM Revisions Added Section 2.07 BROKEN APPOINTMENTS and APPENDIX A ATTACHMENT, Broken Appointment Form. Revised Section 4.06 FILING LIMITS to clarify timely filing requirements. Revised EXHIBIT A � PAGE 52 to provide instructions regarding orthodontic payment for members that become ineligible during treatment and remain in treatment. Revised the ORTHODONTIC CRITERIA INDEX FORM to include criterion CR � Crowding of 7-8 mm in either the maxillary or mandibular arch. Revised Section 9 � CREDENTIALING � to add the requirement for a National Provider Identifier number as an additional credentialing criterion. Added Section 11, Paragraph C., EFFECTIVE COMMUNICATION, to clarify expectations regarding enrollees with special needs, such as interpreter services for persons with communication and language barriers.

41. 41 Contact Information DMAS Smiles For Children Staff: Sandra Brown, MSW: Dental Manager Direct Line: (804) 786-1567 Email: sandra.brown@dmas.virginia.gov Lisa Bilik: Dental Contract Monitor Direct Line: (804) 786-7956 Email: Lisa.Bilik@dmas.virginia.gov Dr. Stephen Riggs, DDS: Dental Consultant Direct Line: (804) 786-6635 Email: stephen.riggs@dmas.virginia.gov

42. Thank You!