an educational presentation presented by: avesis september 2012 prepared for: avesis/wellcare of...
TRANSCRIPT
An Educational Presentation
Presented by: Avesis
September 2012
Prepared For:
Avesis/Wellcare of Kentucky Dental Providers & Staff
Kentucky Dental
Mission Statement
Building long term partnerships to deliver valued, innovative healthcare solutions… one member at a time.
Kentucky Dental
Who We Are
Dental, Vision, and Hearing Plan Administrator working with employer groups and health plans nationally
Over 30 years experience in the dental, vision, and hearing insurance industry
Covering over 4.5 million members throughout the country
Kentucky Dental
Avesis Dental
Dental Networks
Over 30,000 dentists in 41 States
Experienced Administrator
30 years serving corporate and government clients
Avesis administers Medicaid dental plans in 4 states and Medicare Advantage dental plans in 11 states
Kentucky Dental
Avesis is National
Executive Offices in Baltimore, MD
Operations located in Phoenix, AZ
Southeast regional office in Atlanta, GA
Kentucky Dental
Points of Contact
Renee RuggieroAssistant Director of Health Plan [email protected](800) 522-0258 x753
Emori CampbellDental Provider [email protected](800) 522-0258 x178
Carolyn WrightUtilization [email protected](800) 522-0258 x294
Kentucky Dental
Points of Contact
Robin MaysManager, Dental Provider [email protected](800) 522-0258 x136
Angela BridgesProvider Contracting [email protected](800) 522-0258 x156
General Provider Inquiries (855) 214-6776
Kentucky Dental
Clinical Professionals
Dr. Fred SharpeChief Dental [email protected]
Dr. Rick CelkoRegional Dental [email protected]
Dr. Terrence PooleAvesis KY/OH Dental [email protected]
Kentucky Dental
Avesis Dental Advisory Board
Committee of Kentucky licensed Dentists and Avesis staff
Acts in an advisory capacity to Wellcare of Kentucky and Avesis in all matters pertaining to the Avesis/Wellcare of Kentucky Dental Programs
Kentucky Dental
Avesis Dental Advisory Board
Help to ensure quality communications between Kentucky provider community, Avesis, and Wellcare of Kentucky
Forum for providers to submit recommendations and feedback regarding the programs and their administration
Kentucky Dental
Eligibility
Kentucky Dental
Eligibility
It is strongly encouraged that you verify eligibility for each Member’s appointment the business day prior to rendering services unless the next business day is the first day of a new month.
Please note that verification of benefits or eligibility is not a guarantee of payment: actual payment is based on the terms and conditions of the plan in force once the claim is received.
Kentucky Dental
Eligibility
You may obtain eligibility verification four ways:
1. IVR – Please bear in mind that this only provides you with information as to whether or not the member is eligible on the date of service. It does not provide utilization data
2. Website – This method provides you with information as to whether or not the member is eligible on the date of service and allow you to view the members utilization history. (www.Avesis.com or check the state website https://sso.kymmis.com)
3. Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data. You may call 855.214.6776 to reach the Customer service department.
4. Fax – You may utilize the form found of the following slide for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.
Kentucky Dental
Fax Eligibility Verification
Kentucky Dental
Benefits
Kentucky Dental
Benefits Overview
Covered Services
• Covered services will be paid according to the plan fee schedule
Non-Covered Services
• Non-Covered Services may be the responsibility of the member if and only if the Member is notified of and agrees to financial responsibility prior to services being rendered
Kentucky Dental
Benefits Overview
There are two Medicaid programs under Wellcare of Kentucky:
• Global Choices
• Family Choice
Benefits for children (Members ages 20 and under) are the same in each of the plans
Benefits for adults (Members ages 21 and over) vary according to the program in which the Member is enrolled.
Kentucky Dental
The Global Choices Program
Global Choices is the benefit plan for most Kentucky Medicaid members. This plan covers basic medical and dental services. There are no co-pays for any dental services for Wellcare of Kentucky members enrolled in Global choices. Some service limits can be increased if the service is medically necessary (requires prior approval).
Kentucky Dental
Benefits for Global Choices
Global Choices benefits include but are not limited to: • Children under 21:
• 2 cleanings per 12-month period
• 1 set of x-rays per 12-month period
• Extractions and fillings
• Other dental services are available
• Adults 21 and over: • 1 cleaning per 12-month period
• Limited to one dental visit per month
• 1 set of x-rays per 12-month period
• Extractions and fillings
Kentucky Dental
The Family Choices Program
Family Choices is the Kentucky Medicaid benefit plan for most children. This plan covers basic medical and dental services. Kentucky Children’s Health Insurance Program (KCHIP) is part of the Family Choices Plan. This is not a complete list of services. Some benefit limits can be increased if the service is medically necessary (requires prior approval).
Kentucky Dental
Benefits for Family Choices
Family Choices benefits include but are not limited to:
• Children under 21: • 2 cleanings per 12-month period
• 1 set of x-rays per 12-month period
• Extractions and fillings
• Other dental services are available
Kentucky Dental
General Benefits
Benefit Exception/EPSDT Process
• Benefit exception occurs when a provider contacts Avesis requesting services that are non-covered for medical necessity
• Benefits are either exhausted or not a covered benefit
• Requests will be reviewed by Utilization Management and a decision will be made with in two (2) business days.
Emergency Services
• Members seeking emergency services may need to be referred back to Wellcare of Kentucky for medical benefits
Kentucky Dental
Non-Covered Services Disclosure Form
This form is for your protection and the Member pays Usual and Customary Fees
Kentucky Dental
Claims
Kentucky Dental
Claim Submission
Claims may be submitted one of three ways:
Through your practice management software using a clearinghouse
• The Avesis payer identification number is 86098
On an ADA claim form - please submit to the following address:
Avesis Dental ClaimsPO Box 7777Phoenix, AZ 85011 – 7777
Utilizing our website at www.avesis.com
Kentucky Dental
Claims Follow-up
Providers receive remittance advices detailing claims both paid and denied. If you believe you have not received status on a claim, you may check the status of submitted claims two ways:
• You may check claim status on the Avesis website at www.avesis.com
• You may contact our provider services department at (855) 214-6776 to check claim status
Kentucky Dental
Corrected Claims
Submission
• If you are missing information (i.e. tooth number or quadrant number) or you have submitted incorrect information (wrong code, wrong tooth number, etc.) you may edit the claim on the Avesis website regardless of the method of submission.
• If you wish to submit a corrected claim on an ADA claim form you will need to do the following:
• Write corrected claim on the top of the ADA claim form in blue or black ink. The scanner does not read red ink
• Please do not highlight notes on the claim in blue or green highlighter. The scanner reads these colors as black so what ever they highlight is blacked out
Kentucky Dental
Avesis Claims Payment
Check runs weekly
CLEAN CLAIMS processed and adjudicated within 15 business days
Electronic Funds Transfer available for all claims submissions or resubmissions
EFT payments deposited weekly
Kentucky Dental
Electronic Funds Transfer Agreement
Kentucky Dental
Prior AuthorizationPre-treatment Estimates & Benefit Exceptions
Kentucky Dental
Avesis Prior Approval Requirements
Services requiring prior approval are listed in detail in the provider manual and on the covered benefits schedule.
Providers may submit pre-treatment estimates on an ADA claim form to our Phoenix address or via the Avesis website at www.avesis.com.
Avesis accepts electronic attachments via the Avesis web portal.
Kentucky Dental
Chart Reviews
Kentucky Dental
Avesis Office Visits
Avesis conducts office reviews for our dental provider networks
Your office will be contacted in order for Avesis to schedule a time to come out
In addition to a facility walk through, providers will be furnished a list of charts prior to the visit to have available for review
After the visit, your office will be sent a letter regarding the findings of our review
Kentucky Dental
Provider Services
Kentucky Dental
Services to Providers
Avesis is primary for Member and Provider Services
Toll free phones staffed by experienced and knowledgeable representatives from 7am – 7pm EST at 855-214-6776.
State and National professionals involved in professional decisions regarding care and referrals
Regional meetings and training sessions scheduled for providers
Quarterly Provider Newsletters
On-site assistance in your office when available
Peer to peer interaction for Providers
Kentucky Dental
Additional Assistance
Schedule a conference call
Schedule a web demo
Schedule an onsite visit
Kentucky Dental
Committed to Technology
24/7 Access to information:
Web Based
• Eligibility verification
• Claim submission with real time claims processing
• Claim status and editing
• Remittance advice information
• Pre-treatment Estimate
Interactive Voice Response (IVR)
• Eligibility
• Benefits
Kentucky Dental
Thank You For Your TimeQuestions?
We at Avesis look forward to working with you and your team.