Wyoming Medicaid Dental Services Presented by

Veronica Johnson – Veronica.Johnson@conduent.com 307-772-8421

∗ COVID-19 Updates ∗ Provider Enrollment ∗ Attachments ∗ Adjustment/Void Requests ∗ Prior Authorization Updates ∗ Dental Code & Policy Updates ∗ Covered Services ∗ Common Billing Mistakes ∗ Billing with Primary Insurance ∗ Medicaid Website

Discussion Overview

∗ Providers inactive from 1/1/2020 to current for the below were made active: ∗ Current license/certification ∗ Inactivity (15 months of no claims)

∗ Re-enrollment requirements will not cause providers to term ∗ Providers that were termed were made active again

∗ Enrollment certification & Healthcare Provider Agreement CAN be copies/scans/electronic signatures

∗ Provider Agreement blue ink requirement is temporarily waived

Covid-19 Enrollment Exceptions

These Exceptions are only good through the Public Health Emergency!

∗ Active providers are required to re-enroll every 5 years ∗ Providers need to ensure using most up to date forms

when enrolling ∗ New policy as of 4/1/20

∗ All payments done through EFT ∗ If not currently enrolled with Direct Deposit, fill out new W9 and

attach bank letter or voided check ∗ Providers need to ensure sending in most current W9

∗ Can obtain through State Auditor website: ∗ http://sao.wyo.gov/

Provider Enrollment

Attachments

∗ Web portal – Recommended! ∗ Claim & documents match up within 48 hours ∗ Faster payment & provider control

∗ By Mail ∗ PO Box 547, Cheyenne, WY 82001 ∗ Up to 10 business days, depending on mail ∗ Increased human error, delayed payment

∗ Email Wycustomersvc@conduent.com ∗ Up to 10 business days to match up ∗ Increased human error, delayed payment

∗ By Fax - 307-772-8405 ∗ Fax is least reliable method ∗ Your confirmation does NOT = Receipt

Attachment Troubleshooting

∗ Verify Attachment Control Number listed is an EXACT match.

∗ Ensure all fields on the form are populated. ∗ Use the current Suspended TCN/ICN ∗ Use the PDF format to avoid legibility issues. ∗ Always indicate the Pay-To Provider or group. ∗ No attachment indicator results in the claim processing

without the attachment being matched or reviewed. ∗ Multiple attempts can be made to attach if the claim is

still in process.

Resubmitting vs Adjusting

Action Description Timely Filing Limitation

VOID

Claim has paid; however, the provider would like to completely cancel the claim as if it was never billed.

May be completed any time after the claim has been paid.

ADJUST

Claim has paid, even if paid $0.00; however, the provider would like to make a correction or change to this paid claim

Must be completed within six (6) months after the claim has paid UNLESS the result will be a lower payment being made to the provider, then no time limit.

RESUBMIT Claim has denied entirely or a single line has denied, the provider may resubmit on a separate claim.

One (1) year from the date of service.

Options include electronic and paper

∗ PA Requests with missing and/or incorrect information will be pended for updates for 30 days. Will deny if information not received within time frame.

∗ If resubmitting will need to fill out a new request with all information submitted again. ∗ Where to send requests:

∗ Questions about PA ∗ Medical Policy – 800-251-1268

∗ 1.1.4.3

Prior Authorization Update

D9986 ∗ No Show/Broken Appointments ∗ Appointments Canceled or missed by Medicaid clients:

∗ Billing is for tracking purposes only. ∗ Billed amount should be $0.00. ∗ Will show as denial on RA.

∗ May bill client if it is policy to bill ALL patients for missed appointment

Chapter 11 Combined Child and Adult Covered Services

Dental Code & Policy Updates

Code Changes ∗ D8703 maxillary AND D8704

mandibular replaced D8692 for replacement of lost or broken retainer effective 1/1/2020

∗ D1550 was replaced by: ∗ D1551 Bilateral Space

Maintainer- Maxillary ∗ D1552 Bilateral Space

Maintainer – Mandibular ∗ D1553 Unilateral Space

Maintainer

Policy Changes ∗ D8680 updated policy removing

the need to be on a different state’s Medicaid

∗ Updated D8060 to indicate age range of 6-11

∗ D1999 - PPE is allowed with no age limit due to COVID-19 for dates of service 3/01/2020 – TBD ∗ Invoice Required

Personal Protective Equipment

Examinations

Examinations ∗ Children & Adults

∗ D0120-D0180 ∗ D0412

∗ Children only ∗ D0145 (0-3) ∗ D0180 (19-20)

∗ Adults only ∗ D0191 (must be on NH plan for

DOS)

Radiographs & Diagnostic Imaging

∗ Intraoral Complete Series/Panoramic Film ∗ D0210 ∗ D0330

∗ Bitewing x-rays ∗ D0270-D0277

∗ Intraoral ∗ Up to seven allowed per visit ∗ First Film

∗ D0220 – one per visit ∗ Additions films

∗ D0230 ∗ D0240 (children only)

∗ Cone Beam CT ∗ D0367 – Requires Prior Authorization

Preventative Care, Periodontal Treatment & Prosthetics Removable

∗ Preventative Care ∗ Children

∗ D1110-D1120 ∗ D1206-D1208 (0-14) ∗ D1310 (0-3) ∗ D1351-D1354

∗ Adults ∗ D1110

∗ Periodontal Treatment ∗ Children

∗ D4210-D4999

∗ Adults ∗ D4346 ∗ D4355

∗ Prosthetics Removable ∗ Children Only

∗ D5110-D5140 ∗ D5211-D5281 ∗ D5810-D5821 ∗ D5850-D5851 ∗ D5860-D5866

∗ Children & Adults ∗ D5410-D5422 ∗ D5510-D5721 ∗ D5730-D5761

∗ Extractions/Oral and Maxillofacial Surgery ∗ Children Extractions

∗ D7111-7250 ∗ Children Oral and Maxillofacial Surgery

∗ D7111-d7999 ∗ Adults Extractions and Maxillofacial Surgery

∗ D7111-D7140 ∗ D7210-D7241 ∗ D7250 ∗ D7410-D7411 ∗ D7510

∗ Oral and Maxillofacial Surgery ∗ Oral Surgery Procedures not covered using CDT procedure code should be billed using

CPT code on CMS-1500 Claim form. ∗ It is provider responsibility to check covered medical services prior to rendering services ∗ For CPT codes, refer to CMS-1500 Provider Manual ∗ Obtain Prior Authorizations as required

Extractions, Oral & Maxillofacial Surgery

∗ Anesthesia ∗ Dentists may only administer parenteral sedation if they have met

requirements of Wyoming State Board of Dental Examiners or licensing board in the sate they practice and it is within scope of practice ∗ D9222-D9223 ∗ D9239-D9243 ∗ D9248

∗ Sedation and general anesthesia ∗ Not to be billed routinely ∗ Limited to:

∗ patients requiring care and not expected to tolerate treatment ∗ Become unmanageable in usual office setting due to medical, emotional or

developmental limitations ∗ Extent of treatment needs that are documents

∗ Administration of intravenous (IV) or intramuscular (IM) sedation subject to same requirements as general anesthesia

Anesthesia

Dental Services Performed in an FQHC/RHC

Line Procedure Code Date Amount NPI

1 D9999

1/5/19 Fee encounter

rate

Treating Provider

NPI

2 D1120 1/5/19 $0.00 Treating Provider NPI

3 D0240 1/5/19 $0.00 Treating Provider NPI

4 D1120 1/5/19 $0.00 Treating Provider NPI

FQHC/RHC Orthodontics

Line Procedure Code Date Amount NPI 1 D8999 1/5/19 Fee encounter

rate Treating

Provider NPI 2 D8080 1/5/19 $0.00 Treating

Provider NPI

Line Procedure Code Date Amount NPI 1 D8999 2/12/19 Fee encounter

rate Treating

Provider NPI 2 D8670 2/12/19 $0.00 Treating

Provider NPI 3 D8670 3/20/19 $0.00 Treating

Provider NPI 4 D8670 4/30/19 $0.00 Treating

Provider NPI

Banding

Periodic Treatment

Child Covered Services Only

∗ Restorative Treatment ∗ Allowed once per tooth per 18 months

∗ D2140-D2394 ∗ D2510-2664

∗ Crowns ∗ D2710-2934 ∗ See Dental Manual/Fee Schedule for age limitations.

∗ Labial Veneers ∗ D2961-D2962

∗ Endodontics ∗ D3110-D3330 ∗ Include all necessary radiographs during treatment, including pre-op and post-op ∗ Pulpal therapy for primary teeth reimbursable for teeth only not near exfoliation

∗ Cannot bill pulpotomy and root canal therapy on same tooth, only one or the other ∗ Apicoectomy

∗ D3410-D3462 ∗ Radiographs required as part of clinical record ∗ Retrograde filling placed when necessary, billed separately

Child Covered Services Only

∗ Implant Services and fixed Prosthetics ∗ D6010-D6199 ∗ D6205-D6999 ∗ Client must be 17-20 and eligible for Medicaid for permanent tooth replacement

∗ Temporary replacement of lost tooth may be provided to client to maintain space prior to age 17 using appropriate code.

∗ Requesting dentist responsible to determine if client is appropriate candidate for implant or bridge based on completion of growth and neighboring teeth ∗ Documentation of bone density, height and completion of skeletal growth must be in patient

record

∗ Fixed bridges and cast partials only for replacement of permanent teeth ∗ Not reimbursable when done in conjunction with removable appliance in same arch

∗ Occlusal Orthotic Device ∗ D7880 with diagnosis of TMJ

∗ Report of diagnosis and complete treatment place including PT and/or drugs used to treat must be submitted with the claim.

∗ Must be billed on delivery date

∗ D9944 ∗ Hard Occlusal Guard, full arch, PA required

∗ D9955 ∗ Soft Occlusal Guard, full arch, PA required

∗ Nitrous Oxide/Analgesia ∗ D9230

∗ Only reimbursed in conjunction with extractions or restorative procedures

∗ Behavior Management ∗ D9920

∗ Under 10 and/or disabled clients under 21 with recognized mental or physical disability

Child Covered Services Only

Child Covered Services Only

∗ Hospital Calls – ASC or Hospital Outpatient ∗ D9420 ∗ Covered when medically necessary and cost efficient and client cannot

tolerate dental services in office ∗ Must be consistent with diagnosis and treatment of patient’s condition

∗ Other Drugs and Medications ∗ D9630

∗ Can bill if documented need for additional medications

∗ Space Maintenance ∗ D1510-D1517 ∗ D1575 ∗ Must include quadrant on the claim form

∗ UA, UR, UL, LA, LR, LL

∗ Tobacco Counseling ∗ D1320

HEALTH CHECK – Early Periodic Screening, Diagnosis and Treatment program

EPSDT

∗ Suggested Procedures for Dental Services ∗ Birth – 12 months

∗ Clinical Oral Exam ∗ Oral Growth Assessment ∗ Caries Risk Assessment ∗ Radiographic Assessment ∗ Prophylaxis & Topical Fluoride ∗ Fluoride Supplementation ∗ Anticipatory Guidance/Counseling ∗ Oral Hygiene Counseling ∗ Dietary Counseling ∗ Injury Prevention Counseling ∗ Counseling for Nonnutritive Habits

∗ 12 – 24 months ∗ Repeat birth – 12 month procedures every 6 months

∗ Dependent on ∗ Medical Necessity ∗ Index score of 30 on HLD index scale

∗ A parent handout is provided in the form section of the Medicaid website ∗ If less than 30 it will be denied

∗ When to Refer ∗ Cleft lip/palate anomalies ∗ Impacted teeth ∗ Severe bite problems causing problems

∗ Eating ∗ Breathing ∗ Speaking

∗ Misplaced teeth causing destroyed tissue

Referring to Severe Malocclusion Program

∗ Frequency Limitations ∗ Back up documentation, attachment not provided

with claim ∗ IE D9630 – Medicaments ∗ PA Required Claims

∗ No PA indicated on claim ∗ Incorrect PA ∗ Units used

∗ TPL on file but not on claim

Common Billing Mistakes

Billing with Primary Insurance

∗ TPL Billing ∗ Check other insurance box ∗ Other Payer Information

∗ ID (same as line above) ∗ Payer Identification

∗ Other Subscriber Information ∗ Additional other subscriber

∗ Claim filing Code ∗ Payer Responsibility Code

∗ Other Insurance Coverage ∗ Benefits assignment Certification ∗ Release of Information Code ∗ Type Attachment ∗ Transmission Code ∗ Attachment Control number

∗ Backup documentation ∗ Type Attachment ∗ Transmission Code ∗ ACN

∗ Basic Service Line Items ∗ Previously Entered Line Item

Information ∗ Other Svc Info

∗ Service Line Adjudication Information ∗ Other Payer ID ∗ Service line amount pd ∗ Adjudication Date ∗ Pd service unit count ∗ Procedure qualifier ∗ Procedure Code

∗ Basic Claim Form

Billing with Primary Insurance

Wyoming Medicaid Website

∗ Payment Exceptions ∗ Active NPI Listing ∗ Manuals and Bulletins

∗ DME Manual ∗ Dental Fee Schedule ∗ Forms ∗ Provider Training ∗ Web Tutorials ∗ Urgent Announcements (Covid-19, Workshops, etc.)

https://wymedicaid.portal.conduent.com/provider_home.html

∗ Dental Services 1-888-863-5806 ∗ Dental IVR 1-800-251-1270 ∗ EDI Services 1-800-672-4959 (Option 3) ∗ Third Party Liability (TPL) 1-800-251-1268 (Option 2)

Contact information