Lynn Nolf Estrada, AdministratorGeriatric Dental Group of South

TexasSan Antonio, TX

Learning ObjectivesTo understand who is eligible for each

programTo recognize the required forms needed for

each programTo understand the required processes for

each programRecognize the pitfalls that can endanger the

successful utilization of each program

Financial Options for Senior CareForm H1263-B Medicaid Process Full Vendor ProgramSelf-pay

Form H1263-BReceive a completed Form H1263B from the

nursing facility social workerYou must have original signature of the MD,

DO, NP, PA or Clinical nurse specialist on the first page

The 2nd page needs the signature of the resident or their responsible party (RP)

The form must be entirely filled out.The resident must reside in and a licensed

Nursing Facility

Business Manager Checklist Applied income Nursing Home Medicaid #14 effective dateMedical POA or RP and their relation to the

residentWho manages the funding/trustSpouse in the communityGood standing with the facilityHospice

Verified EligibilityContact the nurse and request the following:

Face SheetMARs (Medical Administration Resources)Advance DirectiveHistory & PhysicalMost recent lab workSet appointment with the nurse

Courtesy call to the RP

Initial dental appointmentDevelop treatment plan based upon the

findings from:Complete Oral ExaminationFull Mouth X-rays / PanorexDebridement

RP ConsentsContact the Responsible Party for consents• Treatment Plan• Oral Surgery Consents• Bisphosphonate Consents• Sedation, etc

Memorandum of Understanding

Completed Treatment Once the medically necessary treatment has been

completed. Submit the claim to the Nursing Facility ME worker

Mail original Form H1263-B Itemized Claim form of all completed treatment

Date ADA CodeFee

*Average processing time is about 30 to 45 days

Income AdjustmentThe ME worker approves treatmentThe adjustment is entered in the MESAV

systemThe MESAV reflects the increase in funds

availableThis notifies the nursing facility of an

approvalThe practice will receive one or two forms

showing the approval. This notifies us of the billing direction.

3 possibilities for paymentsForm H1259 – Back-dated payments will

come from the nursing facilityForms H1259 AND H4808 – a mixture of

back-dated funds from the NF and future monthly payments from the fund manager

Form H4808 – Payments to come in consecutive monthly intervals

** Form H1259 changing to H1053

BillingForm H1259Bill the nursing

facilityStatementItemized InvoiceCopy of the 1259

Form H4808Bill the Responsible

PartyStatement

Additional formsH1052-IME

Action Needed Signatures missing Signature not original Description of signer Coding incorrect, etc

H1054-IMEProof Needed

Questionable treatment rendered. State requesting verification that treatment was received.

Full Vendor Program EligibilityThere is no applied income (their SSI is =/<

$60 per month)Nursing Facility Medicaid #14Must be in dental painReside in a licensed Nursing Facility

Necessary Full Vendor FormsForm 2463 Physician Order stating “Dental Pain”Itemized invoice from the dental office

** There is a 1 year submission deadline.

Full Vendor fee schedule Dental Codes and RatesD0140 Emergency Oral Exam $19.16D9110 Emergency Palliative Exam $18.75D0220 X-Rays First Exam $12.82D0230 X-Rays Second and Each Film $11.74D7140 Simple Extraction Single Tooth $67.04D7250 Extraction Root Removal – Exposed Roots $92.50D7210 Surgical Removal of Erupted Tooth $102.81D7220 Removal of Impacted Tooth-Soft Tissue $157.50D7230 Removal of Impacted Tooth – Partially Bony $180.00D7240 Removal of Impacted Tooth – Completely Bony $300.00D7241 Removal of Impacted Tooth – Completely Bony with Complications

$156.25D7250 Surgical Removal of Resident Tooth Roots $92.50D7510 Incision and Drainage of Abscess-Intraoral Soft Tissue $37.50D7520 Incision and Drainage of Abscess-Exta oral Soft Tissue $125.00D9215 Local Anesthesia $12.50D9220 General Anesthesia – First 30 Minutes $87.50D9221 General Anesthesia – Each Additional 15 Minutes $31.25

Self PayResident has no Medicaid or the Medicaid is

pendingWork with the trust fund managerCredit card/checksCareCreditOnce Medicaid is approved, if it is retro-

dated, you can submit the Form H1263-B for their reimbursement

Thank you!Lynn Nolf Estrada, AdministratorPhone: 210.617.4446Fax: 210.617.5572admin @ geriatricdentalgroup.comwww.geriatricdentalgroup.com