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