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Dental Office Reference Manual EFFECTIVE July 1, 2014 DENTAL OFFICE REFERENCE MANUAL LIBERTY Dental Plan Corporation 1 Dental Office Reference Manual LIBERTY Dental LIBERTY Dental Plan Corporation Effective July 1, 2014 Dental Office Reference Manual 1-888-700-0643 This document contains proprietary and confidential information and may not be disclosed to others without written permission. All rights reserved. LIBERTY Dental Plan Corporation, July 1, 2014 Current Dental Terminology ©American Dental Association, All Rights Reserved LIBERTY Dental Plan Corporation 2 Dental Office Reference Manual LIBERTY Dental LIBERTY Dental Plan Corporation Address and Telephone Numbers LIBERTY DENTAL PLAN CORP. IL Department of Healthcare and Family Services (HFS) Customer Service Dental Program Manager 1-888-352-7924 607 East Adams Springfield, IL 62701 1.217.557.5438 Information Systems HFS Provider Hotline [email protected] 1.800.842.1461 Claims Questions HFS Beneficiary Hotline 1-888-352-7924 1.800.226.0768 Prior Authorizations and Retrospective TTY (Hearing Impaired) Hotline Reviews should be sent to: 1.877.204.1012 LIBERTY Dental Plan Corporation Claims P.O. Box 401086 Las Vegas, NV 89140 Dental claims should be sent to: Department of Specialized Care for Children LIBERTY Dental Plan Corporation 2815 West Washington Claims Suite 300, Box 19481 P.O. Box 401086 Springfield, IL 62794-9481 Las Vegas, NV 89140 1.800.322.3722 Dental claims for services performed in a Fair Hearings (Appeals) HFS HOSPITAL should be sent to: Bureau of Administrative Hearings LIBERTY Dental Plan Corporation 401 South Clinton Street, 6th floor Claims Chicago, IL 60607 P.O. Box 401086 1.855.418.4421 Las Vegas, NV 89140 Fraud Hotline 1.800.252.8903 TTY (Hearing Impaired) Fraud Hotline 1.800.447.6404 Questions About IL Managed Care Organizations: Contact Provider Relations at 1-888-700-0643 LIBERTY Dental Plan Corporation, July 1, 2014 Current Dental Terminology ©American Dental Association, All Rights Reserved LIBERTY Dental Plan Corporation 3 Dental Office Reference Manual LIBERTY Dental LIBERTY Dental Plan Statement of Beneficiary Rights and Responsibilities The mission of LIBERTY Dental Plan is to expand access to high-quality, compassionate healthcare services within the allocated resources. LIBERTY Dental Plan is committed to ensuring that all Beneficiaries are treated in a manner that respects their rights and acknowledges its expectations of Beneficiaries’ responsibilities. The following is a statement of Beneficiary rights and responsibilities. 1. All Beneficiaries have a right to receive pertinent written and up-to-date information about LIBERTY Dental Plan, the services LIBERTY Dental Plan provides, the participating dentists and dental offices, as well as Beneficiary rights and responsibilities. 2. All Beneficiaries have a right to privary and to be treated with respect and recognition of their dignity when receiving dental care, which is a private and personal service. 3. All Beneficiaries have the right to fully participate with caregivers in the decision making process surrounding their health care. 4. All Beneficiaries have the right to be fully informed about the appropriate or medically necessary treatment options for any condition, regardless of the coverage or cost for the care discussed. 5. All Beneficiaries have the right to voice a complaint against LIBERTY Dental Plan, or any of its participating dental offices, or any of the care provided by these groups or people, when their performance has not met the Beneficiary’s expectations. 6. All Beneficiaries have the right to appeal any decisions related to patient care and treatment. 7. All Beneficiaries have the right to make recommendations regarding LIBERTY Dental Plan’s/Healthcare and Family Services’ Beneficiary rights and responsibilities policies. Likewise: 1. All Beneficiaries have the responsibility to provide, to the best of their abilities, accurate information that LIBERTY Dental Plan and its participating dentists need in order to provide the highest quality of healthcare services. 2. All Beneficiaries have a responsibility to closely follow the treatment plans and home care instructions for the care that they have agreed upon with their health care practitioners. 3. All Beneficiaries have the responsibility to participate in understanding their health problems and developing mutually agreed upon treatment goals to the degree possible. LIBERTY Dental Plan Corporation, July 1, 2014 Current Dental Terminology ©American Dental Association, All Rights Reserved LIBERTY Dental Plan Corporation 4 Dental Office Reference Manual LIBERTY Dental Statement of Provider Rights and Responsibilities Enrolled Participating Providers shall have the right to: 1. Communicate with patients, including Beneficiaries, regarding dental treatment options. 2. Recommend a course of treatment to a Beneficiary, even if the course of treatment is not a covered benefit, or approved by HFS/LIBERTY Dental Plan. 3. File an appeal or complaint pursuant to the procedures of HFS/LIBERTY Dental Plan. 4. Supply accurate, relevant, factual information to a Beneficiary in connection with a complaint filed by the Beneficiary. 5. Object to policies, procedures, or decisions made by HFS/LIBERTY Dental Plan. Likewise: 1. If a recommended course of treastment is not covered, e.g., not approved by HFS/LIBERTY Dental Plan, the participating dentist, if intending to charge the Beneficiary for the non-covered services, must notify the Beneficiary. See Section 2.01 of the DORM. 2. A provider intending to terminate participation in the HFS dental program due to retirement, relocation or voluntary termination is requested to provide LIBERTY Dental Plan with written notification of termination at least 90 days prior to expected final date of participation. A list of existing Illinois HFS Dental Program patients currently in treatment and the treatment status should accompany the notification. All other HFS patients should be referred to the LIBERTY Dental Plan’s toll-free referral number (1.888.286.2447) to find another dentisit in the area taking referrals when services are needed. 3. A provider may not bill both medical and dental codes for the same procedure. 4. A provider must notify LIBERTY Dental Plan of changes to address, phone, fax, tax ID, or other relevant information. * * * LIBERTY Dental Plan makes every effort to maintain accurate information in this manual; however, LIBERTY Dental Plan will not be held liable for any damages directly or indirectly due to typographical errors. Please contact us should you discover an error. LIBERTY Dental Plan Corporation, July 1, 2014 Current Dental Terminology ©American Dental Association, All Rights Reserved LIBERTY Dental Plan Corporation 5 Dental Office Reference Manual LIBERTY Dental Table of Contents 1.00 Beneficiary Eligibility Verification Procedures and Services to Beneficiaries .................................... 8 1.01 Beneficiary Medical Card .............................................................................................................. 8 1.02 Handbook for Providers of Medical Services ................................................................................ 8 1.03 LIBERTY Dental Plan Eligibility Systems ......................................................................................... 9 1.04 Transportation Benefits for Certain Beneficiaries ......................................................................... 9 1.05 Consent Process for DCFS Wards .................................................................................................. 9 1.06 LIBERTY Dental Plan Customer Service Numbers ........................................................................ 10 1.07 Dental Periodicity Schedule ........................................................................................................ 10 1.08 Managed Care Dental ................................................................................................................. 10 2.00 Covered Benefits ............................................................................................................................. 12 2.01 Benefit Coverage for Medically Necessary Services for Children – EPSDT .................................. 13 2.02 Benefit Coverage for Adults and Pregnant Women .................................................................... 13 2.03 Missed Appointments ................................................................................................................. 14 2.04 Payment for Non-Covered Services ............................................................................................ 14 2.05 Electronic Attachments ............................................................................................................... 14 3.00 Prior Authorization, Retrospective Review, and Documentation Requirements ........................... 16 4.00 Dental Services in a Hospital Setting ............................................................................................... 18 5.00 Claim Submission Procedures ......................................................................................................... 20 5.01 Electronic Claim Submission Utilizing LIBERTY Dental Plan’s Internet Web site ......................... 20 5.02 Electronic Authorization Submission Utilizing LIBERTY Dental Plan’s Internet Website ............. 21 5.03 Electronic Claim Submission via Clearinghouse .........................................................................
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