Texas Provider Training 2013 – Medicaid and CHIP

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Agenda What we offer

Program Information

Main Dental Home

Interim Care Transfer (ICT)

Continuation of Care

Sample EOB

Administrative Reminders

Web portal registration and user set–up process

Web portal overview

Questions and Answers

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What we offer… Web Portal Features

Verify Member eligibility Obtain member claim history Quick and easy claim and authorization entry (free of charge) Upload attachments and x-rays free of charge View status of claims and authorizations Review documents such as Office Reference Manual (ORM) Ability to communicate via secure messaging Notices are posted to the web portal for immediate distribution including

regulatory updates, newsletters, meeting notices and contractual changes

Claims Processing Claims decisions made nearly instantaneously so claims and authorizations

can be viewed much quicker on the portal -usually within 24 hours

Automated Phone System Ability to verify benefits and eligibility and obtain a procedure history Ability to have information faxed back to you Once member information (such as membership number or Date of birth) is

entered, you will be able to jump between menus without re-entering that information.

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PROGRAM INFORMATION

Office Reference Manual Available on web portal and www.dentaquesttexas.com Dental Home Electronic Filing & Attachments Complaints & Appeals Member Rights and Cultural Sensitivity Clinical Criteria Forms (Direct Deposit, Continuation of Care, etc) Complete listing of dental benefits and periodicity

Transportation available for Medicaid members New ITP Service Record completed with provider number and signature Driver submits to TMHP (www.tmhp.com for sample form)

Missed appointments Refer members to Texas Health Steps Outreach Available on web portal

Process for Migrant Farm Worker’s Children Member Advocates

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Main Dental Home…Texas defines a Main Dental Home as the dental provider who supports an ongoing relationship with the client that includes all aspects of oral health care delivered in a comprehensive, continuously accessible,coordinated, and family-centered way. Establishment of a client’s Main Dental Home begins no later than six (6) months of age and includes referrals to dental specialists when appropriate.

The Main Dental Home is a place where a child’s oral health care is delivered in a complete, accessible and family-centered manner by a licensed dentist. This concept has been successfully employed by primary care physicians in developing a “Medical Home” for their patients, and the “Dental Home" concept mirrors the “Medical Home” for primary dental and oral health care. If expanded or specialty dental services are required, the dentist is not expected to deliver the services, but to coordinate the referral and to monitor the outcome.

Members have three (3) available options to change their Main Dental Home: Phone – (Medicaid Members) 1-800-516-0165

(CHIP Members) 1-800-508-6115Effective immediately, but will take 24 hours to show on the portal

Web Entry – www.dentaquesttexas.com , click on “Members” Fax – 1-800-936-0913Both options can take up to three (3) days to complete; however, the effective date will bethe earliest of the appointment date documented on the form or the date received .

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Interim Care Transfer (ICT)…General and pediatric dentists referring a member to another general or pediatric dentist for treatment must submit an interim care transfer (ICT) form. The form must be submitted prior to treatment. At this time, it can only be faxed to DentaQuest. You can access the form on the web portal or www.dentaquesttexas.com under “Provider Information -Important Documents.”

A form is not necessary for a referral to a specialist.

Member has an ICT form on file, please call the contact center at 1-800-896-2374.

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Continuation of Care (COC)… Open Prior Authorizations

Providers must submit a copy of any open prior authorizations with claims

Ensures information needed to avoid any delays in processing DentaQuest will honor authorizations 180 days from the determination

date of the prior vendor

Orthodontic Services

DentaQuest will be receiving authorization information for ortho from Delta Dental just as we did from TMHP. In the event the information is notincluded in the file, DentaQuest’s current COC process will apply.

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SAMPLE Remittance Advice (EOB)

Processing Policy numbers (if applicable) will be listed at the end of each service line. The full description will be listed at the bottom of the page.

The submitted code and the paid code will be listed on the same service line. EOBs will be posted to the web portal for easy access and viewing

DENTAQUEST SERVICES OF ARIZONA, LLC EOB Date: 11/2/2009 Payee ID: 123_456 Group #: 099 Payee Name: AMERICA KIDS Dental Care LLC

Patient Name: SMITH, JOHN Provider Name: ABC HEALTHCARE Claim#: 200930335069800 Subscriber/Member: 00000123456789 Provider/Loc NPI: Referral #: DOB: 11/08/1998 Business NPI: 1770597627 Referral Date: Office Reference No: Group: USA HEALTHCRE

Sub-Group: USA HEALTHCARE -Arizona Medicaid Children SUBMITTED BILLED ALLOWED PAID PAYABLE PATIENT OTHER NET PROCESSING

ITM CODE/TH/SUR DESCRIPTION DOS POS QTY AMOUNT

QTY AMOUNT CODE AMT PAY INSUR AMT POLICIES 1 D0220 PERIAPICAL 05/06/09 11 1 $21.00 1 $0.00 D0220 $0.00 $0.00 $0.00 $0.00 2118

XRAY 2 D0120 PERIODIC ORAL 05/06/09 11 1 $40.00 1 $0.00 D0120 $0.00 $0.00 $0.00 $0.00 2004,2016,2046

EXAM 3 D1120 CLEANING, CHILD 05/06/09 11 1 $50.00 1 $0.00 D1120 $0.00 $0.00 $0.00 $0.00 2016 4 D1330 ORAL HYGEINE 05/06/09 11 1 $50.00 1 $0.00 D1330 $0.00 $0.00 $0.00 $0.00 2004,2016

INSTRUC

5 D1330 ORAL HYGEINE 10/14/09 11 1 $50.00 1 $0.00 D1330 $0.00 $0.00 $0.00 $0.00 2002

INSTRUC

2002 The claim and/or records indicate other coverage. Please provide the subscriber's name, date of birth, d effective ate, and name of the other carrier on this EOB and resubmit for processing. 2004 The Birthday Rule applies to dependent children. Resubmit this claim with the spouse's date of birth. If the spouse's birthday is earlier in the year than our subscriber's then also provide the payment denial of the primary plan. 2016 This procedure has been submitted after the timely filing limit. 2046 Service conflicts with previous service in patient's history. 2118 Service has been bundled to a more cost effective full mouth series

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Administrative Reminders Be sure to verify your provider information is up to date. Please advise us of any

changes to your information as soon as possible.

Submission of electronic claims is highly recommended via our web portal or through a clearing house.

If submitting paper claims, they must be submitted on a 2006 or newer ADA claim form which can be found at www.ada.org.

To ensure your claims are not returned to you, please be sure to: Enter the appropriate NPI numbers in box #49 and #54. Include the treating dentist signature in box #53. Acceptable signatures

include: “Signature on file”, electronic name and typed names. Indicate in box #4 if the member has other insurance. If box 4 is checked “No”,

please skip boxes 5-11 leaving them blank. Check the appropriate Place of Treatment in box #38. If you are submitting an adjustment, void or resubmission of a claim, enter

“adjustment”, “void” or “resubmission” in the remark field box #35.

Do not send in marked-up pre-authorization determination letters when submitting the services for payment. The services should be submitted on an appropriate ADA claim form.

When submitting claims/authorizations via regular mail, please do not also submit the request electronically, as sending both will create duplicate requests.

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Administrative Reminders Methods of submitting claims and authorization (refer to your ORM for further

details) Electronic via DentaQuest’s web portal Common Claims portal Electronic via Clearinghouse (Payer ID CX014) HIPAA compliant 837D File Paper Claims

Open Prior Authorizations Providers must submit a copy of any open prior authorizations with claims Ensures information needed to avoid any delays in processing DentaQuest will honor authorizations 180 days from the determination date

of the prior vendor

Direct Deposit As a benefit to participating Providers, DentaQuest offers Direct Deposit for

claims payments. This process improves payment turnaround times as funds are directly deposited into your banking account.

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We require that x-rays be mounted

Claims received with more than 4 un-mounted x-rays will be returned for mounting

Please make sure the x-rays are of diagnostic quality, properly mounted, dated and identified with the member's name

Below are the options in which you can submit x-rays to us. These are (in order of preference):

Electronically using either NEA (National Electronic Attachment) or the DentaQuest Provider Web PortalMail duplicate x-rays with your ADA formSend original x-rays, your ADA form, and a self addressed stamped envelope (SASE) so that we may return the x-rays to you.

We are unable to return x-rays received without a SASE. X-rays without a SASE will be scanned and recycled.

Refer to your Office Reference Manual to determine if the submission of x-rays is required.

X-Ray Reminders…

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www.dentaquesttexas.com...

Quick access to provider resources:

Training Schedules and presentations – Provider Information / Training Schedule

Office Reference Manual (ORM), Ortho Policy, Interim Care Transfer From – Provider Information / Important Documents

Provider Newsletters (Texas Roundup) – Provider Information / Provider Newsletters

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To Register and create a Super User account (Primary Administrator) access the Registration web page by entering the following URL address: www.dentaquestgov.com/SelfReg/register.aspx

This address is only for the registration of the Super User 

Registration Process

Step 1: Fill out the New User Registration page. All fields are required.

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Step 2: Create a User ID and Password- Please remember this User ID and Password. You will need it to log onto the web portal.

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Step 3: If all the information on the previous page was entered correctly, the below screen will appear. You have successfully completed the Pre-Registration process. You will be able to log onto the new web portal using your new User ID and Password you have just created.

NOTE: When you log onto the new portal you will be able to set-up additional User ID’s and Passwords for employees as needed.

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The Primary Administrator (Super User):Responsible for setting up the users for your group and determining what access they should be allowed. This is determined based on what tier you assign them to and what security role you grant them.

Provider Tiers:Each provider group is set up with 3 separate tiers. The tier will control which offices and providers the user will have access to. User Id’s are allowed to be set up at Tier 1 and Tier 2.

A user assigned to the…. Will be able to access information….

Business Entity (Tier 1)Note: This tier should be assigned security roles 1 through 3.

for all providers at all locations. You should assign a user at this level if you want them to be able to view and/or maintain information for your entire organization (all service offices/locations and providers).

Service Office (Tier 2)Note: This tier should be assigned security roles 1 through 3.

for all providers in a specific location. You should assign a user at this level if you have different staff members who view and/or maintain information for a specific service office/location. User can only view the providers assigned to the specific service office/location.

Individual Provider (Tier 3) User Id’s are not allowed to be set up at this Tier level.

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Security RoleThe Security Role will control what functions the user will be allowed to do.

If a user is assigned the role of….

At the tier they have been assigned they will be able to….

Provider Super User (Role 1) Create and manage user IDs for staff Perform Member Eligibility searches View Remit Advices Check status of Claims and Pre-

authorizations Enter and submit Claims and Pre-

authorizations

Provider office User (Role 2) Perform Member Eligibility searches View Remit Advices Check status of Claims and Pre-

authorizations Enter and submit Claims and Pre-

authorizations

Provider Office User, No Remit (Role 3)

Perform Member Eligibility searches Check status of Claims and Pre-

authorizations Enter and submit Claims and Pre-

authorizations

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Creating Your Office User AccountsOnly Provider Super Users can create new user accounts. Click the Administration menu on the left-side of the page to display the following menu items:

• Dentist List-this menu item allows you to search for and select provider offices or specific dentists that are affiliated with your business entity depending on your Tier Assignment (you can only view your assigned tier and below). Provider Super Users can add and edit users, including resetting passwords, via the Dentist List.

• User List (Provider Super Users Only) This menu item allows Provider Super Users to view and edit user accounts for the tier to which they belong.

Click on Dentist list

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Creating Your Office User AccountsStep by StepStep 1: From the Dentist List page, select the your Business Entity office or the Service Office where you are adding users.

1 Business Entity

2 Service Office

3 Individual

Dentist

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Step 2: On the Dentist Detail page, click the Add Employee link in the upper-right corner of the Provider employees section. The Add Provider Employee page appears.

Step 3:. Type in the employee’s information. Note: Last name and First name are required fields. The others are optional.

Step 4: Click the Submit button to add the new employee. The Provider Employee Detail page appears for that employee.

Creating Your Office User AccountsStep by Step

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Step 5:

In the upper-right corner of the User Account Information section, click the Create User Account link. The Add User page appears.

Creating Your Office User AccountsStep by Step

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Creating Your Office User AccountsStep by Step

Step 6: Select a user role for this employee’s account from the User Role drop-down list.

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Step 7: Enter a user ID for the employee in the User ID field (3-18 characters).

Step 8: Type in an initial password for the employee in the Password field

(6-10 characters).

Step 9: Type the initial password into the Confirm

Password field.

Step 10: Choose a Password Question

Step 11: Enter the Password Question answer.

Step 12: Type the employee’s email address into the Email field.

Step 13: Click the Submit button to create the user

account and notify employee of their

user id and password.

Creating Your Office User AccountsStep by Step

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Web Portal Overview

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Open Microsoft Internet Explorer and access www.dentaquestgov.com and click on Dentists .

Our Corporate Site

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Choose your state from the Select Your State menu then click GO.

Click on the ProviderQuest Web Portal link to access the login page.

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Enter your Username and Password to access the Dentist Home Page

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1. Portal Menus2. Welcome-This section contains

the DentaQuest welcome message.

3. Plan Messages-Contains any plan messages from DentaQuest.

4. Health News-Contains information and news articles of interest.

5. My HealthTools/Resources-contains links to various health resources.

6. Contact-Contains DentaQuest’s contact information.

7. Message Center-Contains messages sent to you from DentaQuest. (appears if you have messages in your Inbox.)

8. FAQ-This link opens to view frequently asked questions.

9. Event Calendar-This link opens the Event Calendar.

10. Related Documents-This link opens the Document List page.

Dentist Home Page

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Adding Billed Amount Lists1. On the Administration menu click on Billed Amount List.

2. Click the Add Billed Amount List link.

3. In the Billed Amount List Name enter the name you want the list to have.

4. In the Code field enter the first code you are entering to the list.

5. In the Fee Amount field enter the fee for the procedure code.

6. Click the plus arrow to add a new code. Repeat step 6 for each procedure code you are adding to the list.

7. Once you have added all the procedure codes and fee amounts, click Submit.

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Adding Billed Amount Lists cont.

8. On the Billed Amount Detail page that appears, click the Add Billed Amount Association link.

9. In the Service Office field on the Add Billed Amount List Association page select the service office you want to associate this list with from the drop-down list.

10. Click the Add button to add the association.

The billed amount list and association is now active for this service office.

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Patient Menu Member Eligibility Search

Performing a Member Eligibility Search

Click Member Eligibility Search in the Patient menu to display the Member Eligibility Search page.

• Select the provider from the Select a Location and Provider drop-down list.

• Type in the Service Date.

• Type in the DOB (date of birth) in mm/dd/yyyy format or select it from the pop-up calendar in the DOB field. *This is a required field.

• You must enter a DOB and Member Number -OR- a DOB and Last Name and partial First Name.

• To add additional rows click Add Member. (Able to search up to 30 members at one time)

• To delete a member from the search, click the Delete link at the end of the row.

• Click Search-the Member Eligibility List page will appear.

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Member Eligibility List

•Active (Eligible): there is a match between the member's active coverage and the dentist's active networks on the date of service.•Ineligible (Not Eligible): the member is not active on the date of service. •Not Found (Member Not Found): a matching member could not be identified.•Click the Member Name link to display the Member Detail page•Click Search Again to redisplay the Member Eligibility Search page and repeat the search process•Click Download File to download the search results•Click on Printer Friendly Format to print the results

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Member Detail Page

• To view benefit maximums (if applicable), click on View Benefit Maximums, the Benefit Maximum detail screen will appear.

• To view a list summary of claims for the specific member, click View Claims; the Claim Status List page appears.

• To view the member’s service history (available if they are eligible), click View Service History; the Member Service History page appears.

• To search for a dentist, click View Provider Directory; the Find a Dentist page appears pre-populated with information for the dentist you selected in the eligibility check.

• The Eligibility Information section lists the current Plan name.• The Other Coverage section lists cross-coverage information (COB) for the member.

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Claims/Pre-Authorization Menu

• Claim/Pre-Authorization Status Search- Use this sub-menu item to search for the status of a claim or pre-authorization

• Remittance Advice Search- Use this sub-menu item to view remittance advice statements

• Dental Claim Entry – Use this sub-menu to enter and submit dental claims

• Dental Pre-Authorization Entry- Use this sub-menu to enter and submit dental pre-authorizations

• Dental Claim Confirmation Report- Use this sub-menu to create a dental claims confirmation report. This report will list all claims that have been submitted through the web for that day.

The Claims/Pre Authorization menu includes the following menu

items:

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Dental Claim Entry

Key

1. Basic Information-Service Date, Group NPI, Service Office, Treating Dentist and POS (Place of Service)

2. Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency, COB,EPSDT, Notes

3. Member Eligibility-DOB, Member ID, Last Name, First Name

4. Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt

5. File Attachments- click Add File to upload an attachment

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Dental Pre-Auth Entry

Key

1. Basic Information-Group NPI, Service Office, Treating Dentist and POS (Place of Service)

2. Optional Information-Accident Type, Accident State, Office Ref#, Referral #, Accident Date, Emergency, EPSDT, Notes

3. Member Eligibility-DOB, Member ID, Last Name, First Name

4. Service Lines-Procedure Code, Tooth, Surface, Quad, Arch, Qty, Service Date, Auth No., Billed Amt

5. File Attachments- click Add File to upload an attachment

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Claim/Pre-Authorization Status Search

Search Criteria Key:

1. Member Last Name

2. Member First Name

3. Member Number

4. Member DOB

5. Servicing Dentist

6.Claim/Pre-authorization Number

7. Type: Dental Claim or Pre- Authorization

8. Status Category: Successfully Entered, Accepted, In Process, Adjudicated, Finalized

9. Date From/To: Enter the Date of Service

10. Claim Received Date From/To: Enter the Claim or Pre-auth Received Date.

This page allows you to conduct a claim or pre-authorization search. **At least one search criteria must be entered to perform a search**

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Claim/Pre-Authorization Status ListThis page appears with any claims or pre-authorizations that met your criteria search

• To download the list, click Download File• To view details on a claim/pre-authorization, click the Claim/Pre-Authorization Number link• To view the member’s details for a claim, click the Member Name link• To view the Dentist Directory Detail page, click the Dentist link for a claim• To perform a new search, click Search Again • To perform a remittance advice search, click RA Search

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Explanation of Benefits Search

• To view the Explanation of Benefits detail, click on Check or EFT Trace Number to display the Remittance Advice Detail page. From the detail page you can view, print or download the remittance advice.

• Click on any column header to sort the results.• Click Download File to download a copy of the results page.

When you click on Remittance Advice Search in the menu the Remittance Advice Search page will appear and will automatically populate your remittance advices.

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Tools Menu

Click the Tools menu to display the sub-menu items:

• User Profile- Use this sub-menu to view your user information and change your name, password, and email address

• Inbox- use this sub-menu to view and manage any messages sent to you

• Contact DentaQuest- use this sub-menu to send secure messages

• Find a Dentist - Use this menu item to search for a specific type of dentist, view detailed provider information, and get directions to a dentist’s office

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Send Secure Messages1. Message Type-select from the

drop-down list: Location Information Change, Provider NPI Info, Provider Authorization, Provider Claims, Remittance Documents

2. Attachment- To add an attachment click on Upload. You can have only one attachment per message

3. Claim/Pre-Authorization Number -Click on Search to search for a claim or pre-authorization

4. Dentist Name- Click on Search to search for a Dentist Name

5. Description-Type your question, comment or suggestion in the text box.

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Questions and Answers