CareSource Dental Program

September 9, 200812:00 – 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

• 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.

•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

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

The following services require prior authorization

• D0321 Other TMJ Films

• D2752 Crown Porcelain w Noble Metal

• 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.

• D3352 Apexification/ recalcificaiton interim visit

• D4210 Gingivectomy/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

• D8220 Fixed 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

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 patients until their treatment is concluded.

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.

Reimbursement

•

Dental Handbook

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CareSource Dental Handbook

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CareSource Dental Handbook

•

CareSource Dental Handbook

Questions