PROVIDER PROVIDER WEBINARSWEBINARS

June 2011

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AGENDA

What’s New What’s Changing What’s NOT Changing Administrative Reminders Web Portal Registration and User Set–Up

Process Web Portal Overview Questions and Answers

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What’s New …What’s New …

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New Web Portal Features Upload attachments and x-rays free of charge Ability to communicate via secure messaging Ability to obtain status of claims and authorizations much quicker Ability to enter broken/missed appointment information via the web

Claims Processing State-of-the-art claims processing system Claims decisions made nearly instantaneously so claims and

authorizations can be viewed much quicker on the portal -usually within 24 hours

New and Improved Automated Phone System Ability to verify benefits and eligibility and obtain a procedure history Ability to have information faxed back to you Once member information (such as membership number or date of

birth) is entered, you will be able to jump between menus without re-entering that information.

What’s New

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Electronic EOBs EOBs will be posted to the web portal for easy access and

viewing.

Electronic Notifications Notices will be posted to the web portal for immediate

distribution including regulatory updates, newsletters, meeting notices and contractual changes.

What’s New

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What’s Changing …What’s Changing …

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When we migrate to the new system, current provider user id and password will no longer be valid. Providers must register on the new web portal. Providers may pre-register the week of June 27 – July 3,

2011 and the week of July 4 – 11, 2011.

Improved security features that allow tiered access and increased provider control.

NPI numbers will be used on all correspondence. Provider ID numbers will no longer be used.

Provider Remittance Advice will have a different look.

Examples of Changes

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The Early and Periodic Screening Diagnosis and Treatment (EPSDT) program is a comprehensive and preventive child health program for individuals under the age of 21.

EPSDT requires that any medically necessary health care services be provided when the service is needed to correct or ameliorate a dental condition. 

Coverage is available under EPSDT for services even if the service is not available under the Smiles For Children to the rest of the Smiles For Children population.

Cases for EPSDT Review

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Effective July 11, 2011July 11, 2011, all services that exceed the benefit limitation or frequency and any service that is listed as not available, must be submitted for Prior Authorization. Provider must check Box #1 – EPSDT/Title XIX of the

2006 ADA Claim Form. Provider must submit the claim using the actual

treatment code. Use of D9999 for EPSDT cases will be discontinued.

If the appropriate box is not checked, the request will be denied.

Cases for EPSDT Review (cont.)

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Processing Policy numbers (if applicable) will be listed at the end of each service line. The full description will be listed at the bottom of the page.

The submitted code and the paid code will now be listed on the same service line. NPI numbers will now be used versus the provider ID numbers.

Remittance Advice (EOB)

DENTAQUEST, LLC EOB Date: 7/11/2011 Payee ID: 123_456 Group #: 099 Payee Name: AMERICA KIDS Dental Care LLC

Patient Name: SMITH, JOHN Provider Name: ABC HEALTHCARE Claim#: 200930335069800 Subscriber/Member: 00000123456789 Provider/Loc NPI: Referral #: DOB: 11/08/1998 Business NPI: 1770597627 Referral Date: Office Reference No: Group: USA HEALTHCRE

Sub-Group: USA HEALTHCARE -Arizona Medicaid Children

SUBMITTED BILLED ALLOWED PAID PAYABLE PATIENT OTHER NET PROCESSING

ITM CODE/TH/SUR DESCRIPTION DOS POS QTY AMOUNT

QTY AMOUNT CODE AMT PAY INSUR AMT POLICIES

1 D0220 PERIAPICAL 05/06/09 11 1 $21.00 1 $0.00 D0220 $0.00 $0.00 $0.00 $0.00 2118

XRAY 2 D0120 PERIODIC ORAL 05/06/09 11 1 $40.00 1 $0.00 D0120 $0.00 $0.00 $0.00 $0.00 2016,2046

EXAM 3 D1120 CLEANING, CHILD 05/06/09 11 1 $50.00 1 $0.00 D1120 $0.00 $0.00 $0.00 $0.00 2016 4 D1330 ORAL HYGEINE 05/06/09 11 1 $50.00 1 $0.00 D1330 $0.00 $0.00 $0.00 $0.00 2004,2016

INSTRUC

5 D1330 ORAL HYGEINE 10/14/09 11 1 $50.00 1 $0.00 D1330 $0.00 $0.00 $0.00 $0.00 2002

INSTRUC

2002 The claim and/or records indicate other coverage. Please provide the subscriber's name, date of birth, d effective ate, and name of the other carrier on this EOB and resubmit for processing.

2016 This procedure has been submitted after the timely filing limit.

2046 Service conflicts with previous service in patient's history.

2118 Service has been bundled to a more cost effective full mouth series

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What’s NOT Changing What’s NOT Changing ……

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Current Web Portal Features (adding enhancements) Verify Member Eligibility Quick and easy claim and authorization entry (free of

charge) View status of claims and authorizations Obtain member claim history Review documents such as Office Reference Manual (ORM)

Electronic Data Interchange (EDI): Electronic claims submission

Same phone numbers and addresses Same payment cycle

What’s NOT Changing …

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Submission of electronic claims is highly recommended via our web portal or through a clearing house.

If submitting paper claims, they must be submitted on a 2006 or newer ADA claim form, which can be found at www.ada.org.

To ensure your claims are not returned to you, be sure to: Enter the appropriate NPI numbers in box #49 and #54. Include the treating dentist signature in box #53. Acceptable signatures include: “Signature on file”, electronic name and

typed names. Indicate in box #4 if the member has other insurance. Check the appropriate Place of Treatment in box #38. If you are submitting an adjustment, void or resubmission of a claim, enter “adjustment”, “void” or “resubmission” in the

remark field box #35. Do not send in marked up pre-authorization determination letters when submitting the services for

payment. The services must be submitted on an appropriate ADA claim form.

When submitting claims/authorizations via regular mail, do not also submit the request electronically. Sending both creates duplicate requests.

Administrative Reminders

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Methods of submitting claims and authorization (refer to your ORM for further details) Electronic via DentaQuest’s web portal Electronic via Clearinghouse HIPPA compliant 837D File Paper Claims

If you are interested in using NEA (National Electronic Attachments) for attachments, we have secured a special deal for you: By mentioning promotion code DQSTSZ when registering (www.nea-fast.com) NEA will

waive the $200 registration fee if you sign up by July 31, 2011sign up by July 31, 2011.

Direct Deposit As a benefit to participating Providers, DentaQuest offers Direct Deposit for claims payments. This

process improves payment turnaround times as funds are directly deposited into your banking account. Please refer to your Office Reference Manual (ORM) for detailed instructions.

Administrative Reminders

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X-ray Policy

We require that x-rays be mounted. Claims received with more than 4 un-mounted x-rays will be

returned for mounting. X-rays must be of diagnostic quality, properly mounted, dated and

identified with the member's name. Below are the options in which you can submit x-rays to us. These

are (in order of preference): Electronically using NEA (National Electronic Attachment) Mail duplicate x-rays with your ADA form Send original x-rays, your ADA form, and a self addressed stamped envelope

(SASE) so that we may return the x-rays to you. We are unable to return x-rays received without a SASE. X-rays without a

SASE will be scanned and recycled. Refer to your Office Reference Manual to determine if the

submission of x-rays is required.

Administrative Reminders

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PURL = Personalized URL

PURL site provides:

Personalized communication

24/7 access to relevant program information via the website

Less paper and waste Secure access Your communications is

password protected Visit the PURL site at: www.DQInfosource.com

Electronic CommunicationsPURL

Administrative Reminders

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Registration Process Registration Process OverviewOverview

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The Primary Administrator (Super User):Responsible for setting up the users for the provider group and determining what access they should be allowed. This is determined based on what tier you assign them to and what security role you grant them.

Provider Tiers:

Each provider group will be set up with 3 separate tiers. The tier will control which offices and providers the user will have access to. User Id’s are allowed to be set up at Tier 1 and Tier 2.

A user assigned to the…. Will be able to access information….

Business Entity (Tier 1)

Note: This tier should be assigned security roles 1 through 3.

for all providers at all locations. A user is assigned at this level if you want them to be able to view and/or maintain information for your entire organization (all service offices/locations and providers).

Service Office (Tier 2)

Note: This tier should be assigned security roles 1 through 3.

for all providers in a specific location. A user is assigned at this level if you have different staff members who view and/or maintain information for a specific service office/location. User can only view the providers assigned to the specific service office/location.

Individual Provider (Tier 3) User Id’s are not allowed to be set up at this Tier level.

New Web Portal Security

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Security Role

The Security Role will control what functions the user will be allowed to do:

If a user is assigned the role of…. At the tier they have been assigned they will be able to….

Provider Super User

(Role 1)

Create and manage user IDs for staff Perform Member Eligibility searches View Remit Advices Check status of Claims and Pre-authorizations Enter and submit Claims and Pre-authorizations

Provider office User

(Role 2)

Perform Member Eligibility searches View Remit Advices Check status of Claims and Pre-authorizations Enter and submit Claims and Pre-authorizations

Provider Office User, No Remit

(Role 3)

Perform Member Eligibility searches Check status of Claims and Pre-authorizations Enter and submit Claims and Pre-authorizations

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Web Portal OverviewWeb Portal Overview

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In the weeks leading up to the migration, providers may receive larger than normal checks. 

As a result of the July 11, 2011 migration, providers will not receive a reimbursement check during the week of July 25, 2011.

Providers may continue to submit claims through the current web portal through July 10, 2011. 

Providers should plan accordingly and prepare for this delay in claims payment. DMAS and DentaQuest will not issue advance pays associated with this delay.

Change in Claims Adjudication Schedule

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A copy of this presentation can be found on the home page of

the current Provider Web Portal (PWP).

QUESTIONS AND ANSWERS