Welcome to DentaQuest! We look forward to working with you to make Texas smile. 2
Agenda • Texas Health Steps Overview • Benefits • Periodicity • Additional Benefit – Medical Transportation Program (MTP) • Questions and Answers 1
Texas Health Steps Medicaid only • Known nationally as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) • Federally mandated health care program focusing on prevention, diagnosis and treatment • Individuals birth through 20 years of age Additional information can be located at: http://www.dshs.state.tx.us/dental/thsteps_dental.shtm 4
EPSDT Benefits • Benefit consists of two mutually supportive, operational components which states and the federal government are responsible for ensuring: • Availability and accessibility of medically necessary health care • Medicaid enrollees and their parents or guardians effectively use the services • CMS is committed to improving pediatric dental care in the Medicaid program and ensuring the appropriate provision of medically necessary dental services to children. 6
First Dental Home… Medicaid Members from six (6) through 35 months of age may be seen for dental checkups by a certified First Dental Home Initiative provider as frequently as every sixty one (61) days if Medically Necessary. The First Dental Home visit (D0145) can be initiated as early as six (6) months of age and must include, but is not limited to, the following: • Comprehensive oral examination • Oral hygiene instruction with primary caregiver • Dental prophylaxis, if appropriate • Topical fluoride varnish application when teeth are present • Caries risk assessment • Dental anticipatory guidance. Providers must be certified to be a Texas Health Steps Dentist. To become a First Dental Home Initiative Provider (Texas Health Steps), the dentist must complete either the online module or in-person training and submit registration information. The Texas Health Steps online First Dental Home Module can be accessed through www.txhealthsteps.com.
Dental Services Preventive • Dental examinations (initial, periodic or problem-focused) • Cleaning (prophylaxis) • Instruction in proper oral hygiene • Application of topical fluoride • Application of sealants to teeth at risk of dental decay • Maintenance of space 7
Dental Services Treatment • Restorations (fillings, crowns) • Endodontic treatment (pulp therapy, root canals) • Periodontic treatment (gum disease) • Prosthodontic (full or partial dentures) • Implants • Oral Surgery (extractions and other procedures) • Orthodontia (braces) if medically necessary (prior authorization required) • Maxillofacial prosthetics 8
Dental Services Emergency and Trauma Related • Procedures necessary to control bleeding, relieve pain, and eliminate acute infection • Operative procedures required to prevent imminent loss of teeth • Treatment of injuries to the teeth or supporting structures 9
Dental Periodicity • Texas Health Steps clients begin to receive periodic dental checkups at 6 months of age and every 6 months thereafter through age 20 • Payment is made for dental checkups that are exceptions to the dental checkup periodicity for the following: • Medically necessary based on risk factors and health needs • Required to meet federal or state exam/checkup requirements for Head Start, day care, foster care, or pre-adoption • Children of Migrant Farm Workers • Client changes their dental home provider 10
Migrant Farm Workers Exceptions… • Children of Migrant Farm workers due for a Texas Health Steps checkup can receive their periodic checkup on an accelerated basis prior to leaving the area. A checkup performed under this circumstance is considered an exception to periodicity. • When the need for an exception to periodicity is established, a narrative explaining the reason for the exception to periodicity limitations must be documented in the member’s file and on the claim submission. In order to submit a claim with an exception, the claim must have the keyword “EXCEPTION” in Block 35 of the ADA claim form or the optional comments field if submitting via DentaQuest’s portal. If the keyword is missing, the claim may deny for exceeding benefit limitations. • Code D1110 or D1120 should be submitted based on the member’s age. • Performing a make-up exam for a late Texas Health Steps checkup previously missed under the periodicity schedule is not considered an exception to periodicity nor an accelerated service. It is considered a late checkup.
Additional Benefit – Medical Transportation Program (MTP) • Transportation to and from appointments is available for Texas Health Steps clients who have no other means of transportation • Arranged by the Medical Transportation Program (MTP) • MTP arranges the most cost effective mode of transportation to meet the client’s needs 11
MTP Related Services For certain Medicaid clients under 21 years of age, MTP services may also include: • Stays at lodging facilities • Meal expenses for the client and one attendant • Travel advances 12
Requests For Service Clients can call the Medical Transportation Program at 1-877-633-8747 to schedule free transportation. 13
Texas Health Steps Outreach… • DentaQuest’s Member Advocates will remind members of their next appointment due date via outbound calls • DentaQuest’s Member Advocates can assist with coordination of care and non-capitated services upon request • Outreach postcards will be sent as a reminder to make appointment every six (6) months • Outreach postcards will be sent to those who have not had a six (6) month visit (non-compliant)