Dental Provider Supplement - AmeriHealthCaritasDC
Addendum ToAmeriHealth Caritas District of Columbia ProviderManualDental Provider SupplementRevised: February 2021Version Seventeen
Table of ContentsWELCOME . 4SHARING OUR MISSION . 4MEDICAID AND ALLIANCE PRODUCTS . 4ABOUT THIS SUPPLEMENT . 4IMPORTANT CONTACT INFORMATION . 5WORKING TOGETHER . 6Supporting providers . 6Supporting members . 6Language access services. 6Consistent, transparent authorization logic . 6Technology . 6Provider website . 7Feedback . 7PROVIDER WEB PORTAL . 8Registration . 8Getting started . 10MEMBER ELIGIBILITY VERIFICATION . 17AmeriHealth Caritas DC eligibility systems . 17SPECIALIST REFERRAL PROCESS. 19PRIOR AUTHORIZATION, RETROSPECTIVE REVIEW, AND DOCUMENTATION REQUIREMENTS19Authorization procedures . 19Procedures requiring prior authorization . 19Retrospective review . 20Participating hospitals . 20CLAIM SUBMISSION PROCEDURES . 21Electronic claim submission using the website. 21Electronic claim submission via clearinghouse . 21HIPAA-compliant 837D file . 21Paper claim submission . 21Timely filing limits . 25Coordination of benefits (COB). 25PROVIDER COMPLAINTS AND APPEALS PROCEDURE . 27Operational complaint: . 27Member appeal: . 27Expedited appeal:. 28Peer-to-peer review:. 30HIPAA . 30CREDENTIALING . 30MEDICAL RECORDKEEPING . 30HEALTH GUIDELINES — AGES 0 – 20 . 33MEDICAID CLINICAL CRITERIA FOR PRIOR AUTHORIZATION OF TREATMENT AND EMERGENCYTREATMENT . 34Criteria for dental extractions . 34Criteria for cast crowns . 34Criteria for endodontics . 35AmeriHealth Caritas District of ColumbiaPage 2
Criteria for stainless steel crowns . 36Criteria for removable prosthodontics (full and partial dentures) . 37Criteria for the excision of bone tissue . 38Criteria for the determination of a non-restorable tooth . 38Criteria for general anesthesia and intravenous (IV) sedation . 39Criteria for short procedure units (SPUs) . 39Criteria for periodontal treatment . 40Orthodontic services for members ages 0 – 20. . 43EXHIBITS A, B, AND C . 46AmeriHealth Caritas District of ColumbiaPage 3
Addendum Two:Dental Provider SupplementWelcomeWelcome to AmeriHealth Caritas District of Columbia (DC) — a mission-driven managed careorganization located in Washington, D.C. We offer two products for members in all eight District wards:AmeriHealth Caritas DC Medicaid (for beneficiaries of the D.C. Healthy Families program) andAmeriHealth Caritas DC Alliance (for beneficiaries of the D.C. Healthcare Alliance program).This supplement to the Provider Manual was created to assist you and your office staff with providingservices to our members, your patients. As a provider, you agree to use this supplement to the ProviderManual as a reference pertaining to the provision of dental services for members of AmeriHealth CaritasDC.The Provider Manual and this supplement may be changed or updated periodically. AmeriHealth CaritasDC will provide you with notice of updates; providers are also responsible to check the plan’s website,www.amerihealthcaritasdc.com, regularly for updates.Thank you for your participation in the AmeriHealth Caritas DC provider network. We look forward toworking with you!Sharing Our MissionAs our provider partner, we invite you to share our mission: To help people get care, stay well, and buildhealthy communities.Medicaid and Alliance ProductsAmeriHealth Caritas DC offers two products in the District: a Medicaid product (for beneficiaries of theD.C. Healthy Families program) and an Alliance product (for beneficiaries of the D.C. Healthcare Allianceprogram). The policies and procedures in this Provider Manual apply to both programs, unless otherwiseindicated. Benefit coverage for Medicaid members differs from coverage for Alliance members. Pleaserefer to the “Provision of Services” section of this Provider Manual for information on covered services foreach program. Medicaid and Alliance members are identified by two different member identification cards,as shown in the first section of this publication.About This SupplementThe information contained in this Dental Provider Supplement is in addition to the information contained inthe AmeriHealth Caritas DC Provider Manual and is intended to apply only to dental providers and to theAmeriHealth Caritas DC dental program. This Dental Provider Supplement includes information on theAmeriHealth Caritas DC dental program that may not otherwise appear in the AmeriHealth Caritas DCProvider Manual.AmeriHealth Caritas District of ColumbiaPage 4
Important Contact InformationPROVIDER SERVICESTelephone: 1-855-609-5170Email: providerportal@AmeriHealthCaritas DCdental.comAUTHORIZATIONSGeneral authorizations:AmeriHealth Caritas DC — AuthorizationsP.O. Box 654Milwaukee, WI 53201Outpatient facility authorizations:AmeriHealth Caritas DC — AuthorizationsP.O. Box 654Milwaukee, WI 53201CONTINUATION OF CAREAmeriHealth Caritas DC – Continuation of CarePO Box 654Milwaukee, WI 53201CREDENTIALINGAmeriHealth CaritasAttn: Credentialing Dept.200 Stevens DrivePhiladelphia, PA 19113Credentialing: 1-877-759-6186Fax: 215-863-6369CLAIMSPaper claims:AmeriHealth Caritas DC-ClaimsP.O. Box 651Milwaukee, WI 53201Electronic claims:Clearinghouse.Payer ID: SCIONProvider Web Portal link pwp.sciondental.comPROVIDER APPEALS OR COMPLAINTS,AmeriHealth Caritas DC — Provider AppealsP.O. Box 1243Milwaukee, WI 53201CORRECTED CLAIMSAmeriHealth Caritas DCP.O. Box 541Milwaukee, WI 53201MEMBER SERVICESMedicaid:202-408-4720 or toll free at 1-800-408-7511Alliance:202-842-2810 or toll free at 1-866-842-2810TTY: 1-800-570-1190Member transportation services:Medicaid members may call:1-800-315-3485.ELECTRONIC FUNDS TRANSFER (EFT)EFT — ApplicationsEmail to: providerservices@skygenusa.comFax: 262-721-0722AmeriHealth Caritas District of ColumbiaPage 5
Working TogetherSupporting providersTo ensure timely, accurate provider reimbursement and high-quality service, AmeriHealth Caritas DC assignseach geographical region a dedicated Dental Program Manager and Dental Director. This proven approach fostersteamwork and cooperation, which results in a shared focus on improving service, member participation, andprogram results.Supporting membersTo further reduce costs for providers while promoting satisfaction, AmeriHealth Caritas DC offers support withtransportation issues and appointment scheduling for members. Providers may also refer members with healthrelated concerns to AmeriHealth Caritas DC to address any questions they may have. This highly successfulprogram reduces administrative costs for dentists and routinely sends satisfied, eligible members directly toprovider practice locations.Providers must offer appointments to members according to Department of Health Care Finance requirements, but inno event less timely than an appointment within 30 days for routine conditions, within 24 hours for urgentconditions, and immediately for emergent situations.Primary dental providers (PDPs) are required to remind members on their PDP panel of missing, due, and overdueappointments. You can access the provider section of our website to assist you with making these reminders.Language access servicesOur members, your patients, must be provided with competent professional oral interpretation services, free ofcharge, utilizing the AT&T Language Access Line (or a comparable service) or through on-site professionalinterpretation services, regardless of the language spoken, at all points of contact, including but not limited to: Appointment scheduling.Office encounters.Provider visits.This also includes translation of documents and other member records. If you are unable to provide these services,it is imperative that you contact Provider Services at (1-855-609-5170), and we will arrange those services forAmeriHealth Caritas DC members.Consistent, transparent authorization logicAmeriHealth Caritas DC’s trained dental program team members use clinical algorithms, which can be customizedto ensure a consistent approach for making Utilization Management (UM) determinations. These algorithms areavailable to providers through the provider portal at www.amerihealthcaritasdc.com so dentists can follow thedecision matrix and understand the logic behind UM decisions. In addition, AmeriHealth Caritas DC fosters asense of partnership by encouraging providers to offer feedback about the algorithms. A consistent, wellunderstood approach to UM determinations promotes clarity and transparency for providers, which in turn reducesprovider administrative costs.TechnologyAmeriHealth Caritas DC takes advantage of technology tools to increase speed and efficiency and keep programadministration and provider participation costs as low as possible.AmeriHealth Caritas District of ColumbiaPage 6
Provider websiteAmeriHealth Caritas DC provides access to a website that contains the full complement of online providerresources. The website features an online provider inquiry tool for real-time eligibility, claims status, andauthorization status. In addition, the website provides helpful information such as required forms, providernewsletter, claim status, electronic remittance advice and electronic funds transfer information, updates, clinicalguidelines, and other information to assist providers in working with AmeriHealth Caritas DC.The website may be accessed at www.amerihealthcaritasdc.com. AmeriHealth Caritas DC’s dental providerwebsite allows network providers direct access to multiple online services. Utilization of the online servicesoffered through the website lowers program administration and participation costs for providers.Internet Explorer and a valid user ID and password are required to access the website. Providers and authorizedoffice staff can log in anytime from anywhere and handle a variety of day-to-day tasks, including: Verify member eligibility and service history reportsView pre-claim estimate reportsAttach supporting documentation to claims and authorizationsSearch for and view historical claims and authorizationsCreate “provider billed amounts” lists for service codesManage patient rosters and schedule appointments on the patient calendarSign up and manage payee electronic funds transfer (EFT) informationCreate and manage portal subaccounts for staffView remittancesFeedbackAt AmeriHealth Caritas DC, feedback from both members and providers is encouraged, logged, and acted uponwhen appropriate. To measure provider and member satisfaction, and to gather valuable feedback for its qualityimprovement initiatives, AmeriHealth Caritas DC makes surveys available from its websites and throughtelephone calls. In addition, to help foster a sense of teamwork and cooperation, AmeriHealth Caritas DC invitesfeedback from providers about its UM algorithms by direct communication with the plan’s Dental Director.AmeriHealth Caritas District of ColumbiaPage 7
Provider Web PortalProvider Web Portal Registration & IntroductionThe AmeriHealth Caritas DC provider web portal allows us to maintain our commitment to help you keep youroffice costs low, access information efficiently, get paid quicker, and submit claims and prior authorizationrequests electronically.RegistrationTo register for the provider web portal, please visit www.amerihealthcaritasdc.com or contact the PortalSupport team at 1-855-434-9239. Additionally, you may contact the Portal Support team to schedule a trainingwebinar or to learn more about the portal’s features and functions.AmeriHealth Caritas District of ColumbiaPage 8
No software downloads or purchasesTo obtain electronic use of our provider web portal all that is required is internet access and a unique username and password.When registering, register “As a payee” so you will have the option to view remittances and be paidelectronically. Contact Provider Support at 1-855-609-5170 to obtain your payee ID number.AmeriHealth Caritas District of ColumbiaPage 9
Getting StartedOnce registered, you can navigate through the web portal and use the available resources and features tohelp streamline data entry.Verify member eligibility You have access to one-step member eligibility verificationYou can check on an unlimited number of patients and print off each summary of eligibilitygenerated by the system for your recordsAmeriHealth Caritas District of ColumbiaPage 10
Manage claims Submit claims for services performedReview and print or save a list of claims submitted today for your records, before they are sent on for processingCheck the status of previously submitted claimsEnter additional information, such as National Electronic Attachment LLC (NEA) number, under the Notes tab
Manage authorizations Submit authorizations before performing services to obtain approvalAttach electronic files, including X-rays, and review authorizations submitted before they are sent on forprocessingCheck the status of previously submitted authorizations
From an authorization summary, you can: Run any applicable authorization guidelinesReview a list of documentation required for each procedure codeAttach electronic files to the authorization recordAttach clearinghouse reference information to the authorization recordPrint a copy of the authorization summary for your records
Electronic Funds TransferAmeriHealth Caritas DC provider web portal services allow us to give you quicker payments by EFT. Electronic paymentoffers the ability to deposit payments directly into your account and allows you to obtain remittances more quickly on youronline account.To obtain your online remittances, navigate to the “Manage My Documents” page from the Documents tab on the toolbar orby the link on the main page.To enroll in EFT payment, please complete the following page and return to AmeriHealth Caritas DC via email atproviderservices@AmeriHealth Caritas DCdental.com or by faxing to 262-721-0722.
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTPART I — REASON FOR SUBMISSIONReason for submission: New EFT authorization Revision to current EFT preferences (e.g., account or bank changes)PART II — PROVIDER OR SUPPLIER INFORMATIONPayee name:Tax identification number (designate SSN or EIN ):Payee address (city, state, ZIP code):PART III — DEPOSITORY INFORMATION (financial institution)Bank/depository name:Depository routing transit number (nine digits; include any leading zeros):Depositor accountnumber (up to 10 digits; include any leading zeros):Account type (check one): Checking SavingsPART IV — CONTACT INFORMATIONBilling contact name:Billing contact phone number:Billing contact email address:PART V — AUTHORIZATIONI hereby authorize AmeriHealth Caritas District of Columbia to initiate credit entries, and, in accordance with 31 CFR part 210.6(f),initiate adjustments for any credit entries made in error to the account indicated above. I hereby authorize the financial institution/banknamed above, hereinafter called the depository, to credit the same to such account. This authorization agreement is effective as of thesignature date below and is to remain in full force and effect until the contractor has received written notification from me of itstermination at such time and in such manner as to afford the contractor and the depository a r
This supplement to the Provider Manual was created to assist you and your office staff with providing services to our members, your patients. As a provider, you agree to use this supplement to the Provider Manual as a reference
DENTAL SCIENCES 1 Chapter 1 I Dental Assisting— The Profession 3 The Career of Dental Assisting 4 Employment for the Dental Assistant 4 The Dental Team 6 Dental Jurisprudence and Ethics 12 Dental Practice Act 12 State Board of Dentistry 12 The Dentist, the Dental Assistant, and the Law 13 Standard of Care 13 Dental Records 14 Ethics 14
Cigna Dental Care DMO Patient Charge Schedules 887394 09/15 CDT 2016 Covered under Procedure Code1 Dental Description and Nomenclature Cigna Dental 01 and 02 PCS Cigna Dental 03 PCS Cigna Dental 04 PCS Cigna Dental 05 PCS Cigna Dental 06 PCS Cigna Dental 07 PCS Cigna Dental 08 PCS Chair Time Per Y/N Minutes Code # (if different) Y/N Code # (if .
is a detailed list of dental services provided by a dental office and given to Delta Dental for payment. Delta Dental means Delta Dental Plan of Michigan, Inc., a service provider for dental benefits under the Michigan Dental Program. Delta Dental ID Card is a permanent (not monthly) card. We send
Mid-level dental providers, variously referred to as dental therapists, dental health aide therapists and registered or licensed dental practitioners, work as part of the dental team to provide preventive and routine dental services, such as cleanings and fillings. Similar to how nurse practitioners work alongside physicians, mid-level dental .
DELTA DENTAL. Delta Dental of North Carolina . SM . DELTA DENTAL PPO PARTICIPATION APPLICATION AND AGREEMENT Delta Dental Provider Records, PO Box 30416, Lansing, MI 48909-7916 Phone (800) 656-6495 . I hereby apply to Delta Dental of North Carolina (a non-profit dental service corporation, hereinafter referred to as DDNC) to become a
network providers Blue Cross Medica South Country Health Alliance UCare Health Plan Provider Resources Provider Customer Service Delta Dental Provider Customer Service: 651-406-5907 or 1-800-774-9049 TTY 711 Provider Services: 952-967-7998 or 1-866-885-8880 TTY 952-883-6060or 1-800-443-0156 Delta Dental Provider Customer Service: 651-406-5907 or
Jun 14, 2016 · active duty Soldiers treated at any of five dental clinics on Fort Bragg. These clinics included Davis Dental Clinic, Joel Dental Clinic, LaFlamme Dental Clinic, Pope Dental Clinic, and Smoke Bomb Hill Dental Clinic. For each appointment the appointment type, date, and dental wellness class
BEC HIGHER AD BE 3 C The growth of outsourcing means that a number of MSSs are finding themselves drawn into the established managerial thinking of their OWOs to a point where their reputation becomes dependent on the OWO’s performance – in both positive and negative ways. This and other consequences of growth are generating calls from MSSs for both the private sector and governments to .
