GATEWAY Health Plan Dental Reference Guide Medical Assistance Program
Administered by United Concordia December 2009
GATEWAY HEALTH PLAN DENTAL REFERENCE GUIDE
TABLE OF CONTENTS
INTRODUCTION
SECTION 1 SUPPORT SERVICES
Communication Sources ........................................................................ 1.1
Dental Professional Relations Representatives ..................................... 1.1
Dental Customer Service Representatives ............................................ 1.2
Interactive Voice Response (IVR) System ............................................. 1.2
My Patients Benefits.............................................................................. 1.3
Dental Reference Guide......................................................................... 1.3
Dentist Newsletter .................................................................................. 1.3
Special Mailings ..................................................................................... 1.4
Internet ................................................................................................... 1.4
Mailing Addresses for Claim and Prior Authorization Submissions........ 1.4
Mailing Addresses for Inquiries .............................................................. 1.5
Telephone Numbers............................................................................... 1.6
Helpful Websites .................................................................................... 1.6
SECTION 2 AUTOMATED SERVICES
My Patients Benefits.............................................................................. 2.1
Interactive Voice Response (IVR) System ............................................. 2.1
Provider Check Information.................................................................... 2.2
Identification Cards................................................................................. 2.2
Confirm Eligibility.................................................................................... 2.3
DPW Eligibility Verification ..................................................................... 2.3
Member Benefit Packages ..................................................................... 2.3
Program Exception................................................................................. 2.4
SECTION 3 PARTICIPATING WITH SMILENET
Advantages of Participation.................................................................... 3.1
How to Become a Participating Dentist .................................................. 3.2
Confidentiality......................................................................................... 3.3
Credentialing .......................................................................................... 3.3
Internal Peer Review.............................................................................. 3.4
How Individual Provider ID Numbers Are Established ........................... 3.4
Group Practice ....................................................................................... 3.5
How to Form a Group Practice............................................................... 3.5
Medicaid DRG_11.20.09 www.unitedconcordia.com Current Dental Terminology American Dental Association
http:www.unitedconcordia.comhttp:DRG_11.20.09
Changes in Group Practice Membership / New Associates................... 3.6
Maintaining Dentist Data ........................................................................ 3.6
Where to Send Notification of Change(s)............................................... 3.7
How to Resign from Participation ........................................................... 3.7
Gateway Members Rights and Responsibilities .................................... 3.7
Self-Referral ........................................................................................... 3.8
EPSDT Dental Referral .......................................................................... 3.8
Dental Referral ....................................................................................... 3.9
Specialty Care Providers........................................................................ 3.9
Example: Credentialing Application Example: Participating Dentist Agreement with SmileNet Example: Request for Dental Group Account (Addendum C) Example: Request for Addition and/or Deletion of a Participating Provider(s) Identification Number to an Existing Group Account (form 5704)
SECTION 4 POLICIES, LIMITATIONS AND EXCLUSIONS
Benefits and Exclusions - General Policies............................................ 4.1
Documentation Required For Specific Services..................................... 4.2
Prior Authorizations ................................................................................ 4.2
Requesting a Prior Authorization............................................................ 4.3
Full Benefit Coverage - Covered Services ............................................. 4.4
Full Benefit Coverage Benefits and Limitations................................. 4.13
Limited Benefit Coverage - Covered Services ..................................... 4.19
Limited Benefit Coverage Benefits and Limitations........................... 4.27
Procedure Code Reporting Chart......................................................... 4.43
Diagnostic Material Requirements Chart ............................................. 4.49
SECTION 5 ORTHODONTICS
Orthodontic Prior Authorizations ............................................................ 5.1 Orthodontic Treatment Plans ................................................................. 5.2 Orthodontic Services
Full Benefit Coverage Covered Services................................. 5.3
Benefits and Limitations for Orthodontic Services...................... 5.3
Payment for Orthodontic Services.......................................................... 5.4
Transferring Orthodontists.......................................................... 5.4
Orthodontic Treatment In Progress.......................................... 5.4
New Enrollee .............................................................................. 5.4
Transferring from Another Dentist .............................................. 5.5
Billing Orthodontic Services ................................................................... 5.6
Billing for New Orthodontic Patients....................................................... 5.6
How to Complete a Dental Claim Form for New Orthodontic Patients... 5.6
Billing for New Patients In Progress..................................................... 5.7
Orthodontic Inquiries .............................................................................. 5.8
Example: Salzmann Index Report........................................................ 5.9
Medicaid DRG_11.20.09 www.unitedconcordia.com Current Dental Terminology American Dental Association
http:www.unitedconcordia.comhttp:DRG_11.20.09
Salzmann Index Instructions ................................................................ 5.11
SECTION 6 CLAIM SUBMISSION GUIDELINES
Completing the Claim Form.................................................................... 6.1
Claim Filing Deadline ............................................................................. 6.3
Gateway Health Plan ID Number ......................................................... 6.3
Signature Requirements......................................................................... 6.4
Treatment Plan /Release of Information................................................. 6.4
Dentists Signature ................................................................................. 6.4
Supporting Documentation..................................................................... 6.5
Other Supporting Documentation........................................................... 6.5
Prior Authorizations ................................................................................ 6.6
Requesting a Prior Authorization............................................................ 6.6
Prior Authorizations and Coordination of Benefits.................................. 6.7
Timeframes and Written Notification ...................................................... 6.7
Treatment without Prior Authorization .................................................... 6.8
Hospitalization / Short Procedure Unit (SPU) Procedure ....................... 6.8
Claim Review Process ........................................................................... 6.8
Initial Review .......................................................................................... 6.9
Professional Review by Dental Advisors................................................ 6.9
Example: Gateway Health Plan Claim Form.................................... 6.10 Example: Dental Authorization Form for Medical Facility/Inpatient Services
SECTION 7 ELECTRONIC CLAIM SUBMISSION
Speed eClaimSM ..................................................................................... 7.1
Electronic Data Interchange (EDI).......................................................... 7.1
Benefits of Submitting Claims E