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 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 Member’s 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 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 Dentist’s 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 Electronically .......................................... 7.1 How to Become Eligible to Submit Electronic Claims ............................ 7.2 Submitting Claims Requiring Attachments ............................................. 7.3 Reports................................................................................................... 7.3 997 Functional Acknowledgement Report.................................. 7.3 277 Claims Acknowledgement Report ......................................