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CareSource Dental Program September 9, 2008 12:00 – 1:00. Welcome!. Introductions: Dr. Terry Torbeck, Vice President/Senior Medical Director Dr. Gary Ensor – CSMG Dental Consultant Cheryl Slagle, RN, CMCN, CCM Director Medical Management
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CareSource Dental Program September 9, 2008 12:00 – 1:00
Welcome! Introductions: • Dr. Terry Torbeck, Vice President/Senior Medical Director • Dr. Gary Ensor – CSMG Dental Consultant • Cheryl Slagle, RN, CMCN, CCM Director Medical Management • Meloney Porter, RN Team Lead for Dental Services • Candace Owens, Senior Dental Coordinator
Agenda • Review Adult Dental Benefit changes • Review communications sent to providers including benefit and prior authorization changes • Review CareSource prior authorization requirements and benefits • Overview of the CareSource Dental Handbook
Restored Adult Dental Benefits • Adult dental benefits restored effective July 1, 2008 • Restoration of the Medicaid adult dental benefits - applies to all Ohio Medicaid Covered that was in place until December 31, 2005.
Restored Adult Dental Benefits • D2933 Prefab Stainless Steel Crown • D2952 Post & Core Cast + Crown • D3320 Root Canal Therapy bicuspids • D3330 Root Canal Therapy molars • (Note: Root canals require PA if 3 or more root canal procedures are scheduled within 6 months). • D3351 Apexification/recalcification initial visit • D3352 Apexification/recalcification interim visit • D3353 Apexification/recalcalcification final visit • D3410 Apicoectomy/Periradicular Surgery Anterior • D0321 Other TMJ Films • D1510 Space Maintainer Fixed Unilateral • D1515 Fixed Bilateral Space Maintainer • D1520 Space Maintainer Removable Unilateral • D1525 Space Maintainer Removable Bilateral • D2752 Crown Porcelain w Noble Metal • D2930 Prefab Stainless Steel Crown Primary • D2931 Prefab Stainless Steel Crown Perm.
Restored Adult Dental Benefits • D4210 Gingivectomy/Plasty Per Quad • D7220 Impact Tooth Removal Soft Tissue • D7230 Impact Tooth Removal Partial Bony • D7240 Impact Tooth Removal Comp Bony • D7241 Impact Tooth Removal Bony w Comp • D7250 Tooth Root Removal • D7270 Tooth Reimplantation • D7280 Surgical Access Unerupted Tooth • D7310 Alveoplasty w Extraction • D7320 Alveoplasty wo Extraction D7471 Removal Exostosis Any Site D7671 Alveolus Open Reduction D7899 TMJ Unspecified Therapy D7960 Frenulectomy/Frenulotomy D7970 Excision Hyperplastic Tissue D8210 Orthodontic Removable Appliance Treatment D8220 Fixed Appliance Therapy Habit Y7255 Remove Supernumary Tooth
Dental Provider Communication • Mailed in mid July • Outlined Medicaid restored adult dental benefits • Defined CareSource prior authorization requirements • Introduced the revised CareSource Dental Handbook • Defined upcoming changes to the process for Orthodontia management and billing
D0321 Other TMJ Films D2752 Crown Porcelain w Noble Metal D2952 Post & Core Cast + Crown D3320 Root Canal Therapy bicuspids D3330Root Canal Therapy molars Note: Root Canals require PA if 3 or more root canal procedures are scheduled within 6 months. D3352 Apexification/ recalcificaiton interim visit D4210Gingivectomy/Plasty Per Quad D7240 Impact Tooth Removal Comp Bony D7241 Impact Tooth Removal Bony w Comp D7250 Tooth Root Removal D7280 Surgical Access Unerupted Tooth The following services require prior authorization
D7471 Removal Exostosis Any Site D7899 TMJ Unspecified Therapy D7960 Frenulectomy/ Frenulotomy D7970 Excision Hyperplastic Tissue D8210 Orthodontic Removable Appliance Tx D8220Fixed Appliance Therapy Habit Y7255 Remove Supernumary Tooth D5110 Complete Upper Denture - Maxillary D5210 Complete Lower Denture - Mandibular D5211 Maxillary Upper Partial Denture - Resin Base D5212 Mandibular Lower Partial Denture - Resin Base D5213 Maxillary Upper Denture Partial – Cast metal D5214 Mandibular Lower Denture Partial - Cast metal The following services require prior authorization
Orthodontia • As required by Ohio Administrative Code, coverage of comprehensive orthodontics is limited to the most severe handicapping orthodontic conditions. • Comprehensive orthodontics should be considered only after eruption of permanent centrals, laterals, first molars and first premolars. Exceptions can be made in the case of severe maxillary and / or mandibular growth abnormalities. • Coverage is limited to patients younger than 21. • Only one course of comprehensive orthodontic treatment per person, per lifetime is covered and is capped at a total dollar amount.
Orthodontia Changes • Current CareSource orthodontia review policy will be in effect until October 1, 2008. • Beginning October 1, a two-step review process will be required. • Please refer to pages 16-19 of the CareSource Dental Handbook for detailed information.
Orthodontia Changes • Step 1: Evaluation for Orthodontia Referral • The referring dentist or orthodontist must submit a request for orthodontic workup. • Required Documentation: • Orthodontic predetermination form • A diagnostic complete set of radiographs OR a diagnostic panoramic radiograph OR photos showing the patient's bite and occlusal view • Any other supporting documentation • If it is determined that the patient’s condition meets the established CareSource/ODJFS guidelines as having the most severe handicapping orthodontic condition, an authorization for a comprehensive orthodontic workup will be given.
Orthodontia Changes • Step 2:Orthodontic Workup • If, after the orthodontic workup, the orthodontist believes the member may meet the CareSource/ODJFS guidelines as having the most severe handicapping orthodontic condition, the orthodontist must submit a request for comprehensive orthodontic treatment. • Required Documentation: • A diagnostic complete set of radiographs OR a diagnostic panoramic radiograph • Properly trimmed study or computer models (preferred) • Cephalometric films (D0340)-no tracings • Lateral and frontal photographs of the patient with lips together • Any other supporting documentation
Orthodontia Changes • Step 2:Orthodontic Workup(cont.) • If the request for comprehensive orthodontic treatment is approved, an authorization will be sent to the requesting provider which will provide authorization for the entire course of treatment (as long as the patient remains an eligible CareSource member.
Orthodontia Changes • Beginning October 1, 2008 orthodontia reimbursement for maintenance services will have the following changes: • Monthly billing cycle (D8030 Monthly Orthodontic Treatment) instead of quarterly for new starts only. • For ease of billing, orthodontists can continue quarterly claims submission for new patients by submitting 3 of the D8030 monthly charges if the patient was enrolled and actively being treated during that quarter. • The quarterly billing cycle (D8670 Quarterly Orthodontic Treatment) should be continued for existing patientsuntil their treatment is concluded.
Reimbursement Per Ohio Administrative Code 5101:3-1-60 Medicaid reimbursement: Payment for a covered service constitutes payment-in-full and may not be construed as a partial payment when the reimbursement amount is less than the provider’s charge. The provider may not collect and/or bill the consumer for any difference between the payment and the provider’s charge or request the consumer to share in the cost through a deductible, coinsurance, co-payment or other similar charge.
Reimbursement • CareSource absorbs any member co-payments. • The cost of analgesic and local anesthetic agents is included in the fees associated with covered dental services and is not reimbursed separately.
