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  1. Presentation prepared for: Avesis Health Partners Dental Providers & Staff

  2. 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

  3. 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 5 states and Medicare Advantage plans in 9 states

  4. Avesis is National • Executive Offices in Baltimore, MD • Operations located in Phoenix, AZ • Southeast regional office in Atlanta, GA • Local representatives located in Pennsylvania

  5. Avesis Staff Contact Information • Nichole Mitchell – Director, Government Programs (800) 522 – 0258, ext. 296 • Dale Woodie – PA State Program Manager (800) 522 – 0258, ext. 135 • Kelley Owens – Senior Provider Relations Rep (800) 522 – 0258, ext. 738

  6. Avesis Staff for Health Partners • Carolyn Wright – Utilization Management (800) 522 – 0258, ext. 294 • Tracye Mash – Utilization Management (800) 522 – 0258, ext. 119 • Provider Services ( 855) 536 - 7764

  7. Avesis Clinical Professionals • Dr. Fred Sharpe – Chief Dental Officer • Dr. Rick Celko – Regional Dental Director • Dr. Martin Weinberg – Philadelphia Dental Director • Dr. Dan Pituch – Avesis PA Medical Director

  8. 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

  9. 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.

  10. 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 Member’s 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.

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


  13. 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.

  14. 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.

  15. 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.



  18. Benefits • 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.

  19. 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 Children’s 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.

  20. 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.

  21. General Benefits • Benefit Exception 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 Health Partners for medical benefits

  22. 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.

  23. 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 screens performed. • All relevant medical information, including the results of the EPSDT screens, are to be incorporated into the Member’s primary medical record.

  24. 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

  25. Benefit Limits • Effective April 1, 2012, Health Partners adult members (age 21 and older) will experience a change to their dental benefit that will limit 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 Member’s benefit limits are not covered unless a BLE is requested and approved by Avesis.

  26. 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.

  27. Benefit Limits • Effective April 1, 2012, Health Partners ‘adult members (age 21 and older) will be 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)

  28. Benefit Limits • NOTE: The dental benefit changes donotapply 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).

  29. 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 Usual and Customary Fees

  30. CLAIMS

  31. 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

  32. 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 • You may contact our provider services department at (855) 536 - 7764 to check claim status.

  33. 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.

  34. 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

  35. Electronic Funds Transfer Agreement


  37. 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 with all pertinent clinical information to accompany the request.

  38. 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.

  39. ADA Claim Form for Pre-Treatment Estimate

  40. 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.

  41. Requesting a Benefit Limit Exception • Avesis will grant benefit limit exceptions to the dental benefits when one of following criteria are met: • 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.

  42. 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 request being sent back to the requesting office as not being able to be processed. • A completed Avesis Dental BLE request form which has been included herein for your reference.

  43. Dental BLE Form

  44. 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 is over the benefit limit. • Retrospective BLE requests received on or after the 61st day from the date of the claim rejection will be denied.

  45. 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. • When Avesis denies a BLE request, both the provider and Member will receive a written notice of the decision that explains the reason for the denial.


  47. 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


  49. 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

  50. 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