presentation prepared for: avesis health partners dental providers & staff

Presentation prepared for:Avesis Health Partners Dental Providers & Staff

Who is Avesis?Mission Statement:

Building long term partnerships to deliver valued, Innovative Healthcare Solutions… one member at a time.

Dental, Vision and Hearing Plan Administrator working with employer groups and health plans nationally

Over 30 years experience in the dental, vision, and hearing insurance industry

Who is Avesis Dental?

Dental Networks - over 30,000 dentists in 41 States

Experienced Administrator – 30 years serving corporate and government clients

Avesis administers Medicaid plans in 3 states and Medicare Advantage plans in 11 states

Avesis is National

Executive Offices in Baltimore, MD

Operations located in Phoenix, AZ

Southeast regional office in Atlanta, GA

Local representatives located in Pennsylvania

Avesis Staff Contact Information

Renee Ruggiero– Asst Dir of Health Plan Servicesrruggiero@avesis.com (800) 643 – 1132, ext. 753

Dale Woodie – PA State Program Manager dwoodie@avesis.com (800) 522 – 0258, ext. 135

Kelley Owens – Senior Provider Relations Repkowens@avesis.com (800) 522 – 0258, ext. 738

Provider Services( 855) 536 - 7764

Avesis Clinical Professionals Dr. Fred Sharpe – Chief Dental Officer

Dr. Rick Celko – National Dental Director of Utilization Management and Clinical Integrity

Dr. Dan Pituch – Avesis PA Medical Director

Avesis Dental Advisory Boards Committee of licensed PA Dentists and Avesis staff

Act in an advisory capacity to Health Partners Health Plan and Avesis in all matters pertaining to the Health Partners Dental Programs

Help to ensure quality communications between PA provider community, Avesis and Health Partners Health Plan

Forum for providers to submit recommendations and feedback regarding the programs and their administration

Cultural Competency As a company dedicated to providing clients with

superior service, Avesis fully recognizes the importance of serving Members in a culturally and linguistically appropriate manner. We know from direct experience that: Some Members have limited proficiency with the English language

including some Members whose native language is English but who are not fully literate.

Some Members have disabilities and/or cognitive impairments that impede their communicating with us and using health care services.

Some Members come from other cultures that view health-related behaviors and health care differently than the dominant culture.

Cultural Competency To be culturally competent, Providers shall:

Work with Members so that once Members are identified that may have cultural or linguistic barriers alternative communication methods can be made available.

Utilize culturally sensitive and appropriate educational materials based on the Member’s race, ethnicity and primary language spoken.

Ensure that resources are available to overcome the language barriers and communication barriers that exist in the Member population.

Make certain that you recognize the culturally diverse needs of the population.

Teach staff to value the diversity of both their co-workers inside the organization and the population served, and to behave accordingly.

Special Needs Avesis works in coordination with the Special Needs

Unit at the Health Plan to ensure that the dental needs of every Member are met.

If you have a Special Needs Member that requires help in securing dental treatment, Avesis can assist in coordinating an appropriate referral to a dental Provider who is able to meet the Member’s specific needs.

ELIGIBILITY

EligibilityIt is strongly encouraged that you verify eligibility for each Member’s appointment the business day prior to rendering services unless the next business day is the first day of a new month. Please note that verification of benefits or eligibility is not a guarantee of payment: actual payment is based on the terms and conditions of the plan in force once the claim is received.

EligibilityYou may obtain eligibility verification four ways:

1. IVR – Please bear in mind that this only provides you with information as to whether or not the member is eligible on the date of service. It does not provide utilization data

2. Website – This method provides you with information as to whether or not the member is eligible on the date of service and allows you to view the members utilization history.

Eligibility3. Customer service – Customer service is able to

provide you with both eligibility confirmation as well as utilization data.

4. Fax – You may utilize the form found on the following slide for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.

ELIGIBILITY VERIFICATION FORM

BENEFITS

Health Partners Health Plans Health Partners has two different programs:

Health Partners – the program for Medical Assistance Members

KidzPartners – the program for Pennsylvania CHIP members

Benefits vary according to the program in which the Member is enrolled.

General Overview Health Partners offers dental care to eligible Medical

Assistance recipients in the Health Partners Health Plan service area.

KidzPartners is available through a contract with the Children’s Health Insurance Program (CHIP) of Pennsylvania. CHIP is a State and Federally funded program to provide health

insurance for uninsured children from birth until they reach the age of 19.

In 2007, Pennsylvania CHIP was expanded to offer health insurance to children and teens who are not eligible for Medical Assistance, regardless of family income.

Enrollment eligibility is evaluated every 12 months.

General Benefits Covered Services

Covered services will be paid according to the plan fee schedule

Non-Covered Services Non-Covered Services may be the responsibility of the

member In order to be responsible for payment of non – covered

services, Member must be notified of financial responsibility prior to services being rendered and the provider must obtain written verification of this notification.

Non-Covered Services Disclosure Form

Providers must obtain a written indication from Avesis that any proposed services are truly non-covered service for the Member in question prior to collecting a fee from the Member.

Member pays 80% of Provider’s Usual and Customary Fees

General Benefits Program Exception Process

A program exception occurs when a provider contacts Avesis requesting services that are non-covered for medical necessity

• Benefits are either exhausted or not a covered benefit» Requests will be reviewed by Utilization

Management and a decision will be made with in two (2) business days.

Emergency Services Members seeking emergency services may need to be

referred back to Health Partners for medical benefits

Benefit Changes Effective 2013 There were changes to KidzPartners effective

January 1, 2013. Members enrolled in KidzPartners will no longer have access to an expanded

dental benefit. This expanded dental benefit (EDB) was only available for calendar year 2012. The annual maximum for all services is $1500.00.

The orthodontic benefits will no longer be reimbursed at a case rate. Beginning with new cases banded 1/1/2013 and after, Avesis will be paying based upon the previous process of an initial banding fee followed by quarterly payments. All newly approved and billed orthodontic cases for 2013 will be reimbursed with a banding fee, up to seven quarterly fees and retention. This reimbursement will mirror how you are currently being reimbursed through the Health Partners Medicaid benefits.

Benefit Limits Effective April 1, 2012, Health Partners adult

members (age 21 and older) experienced a change to their dental benefit that limits the following dental services: Periodic oral evaluations (D0120) Prophylaxis, adult (D1110) Dentures, both complete and partial (D5110, D5120,

D5130, D5140, D5211, D5212, D5213, D5214) Services provided beyond a Member’s benefit limits

are not covered unless a BLE is requested and approved by Avesis.

Benefit Limits The Benefit Limits are as listed below:

Periodic oral evaluations (D0120) will be limited to one (1) per 180 days per adult Member. NOTE: Providers will not be paid for a periodic oral evaluation (D0120) and a comprehensive oral evaluation (D0150) within the same 180 day time period.

Prophylaxis, adult (D1110) will be limited to one (1) per 180 days per adult Member.

Dentures will be limited to one per upper arch, full or partial, regardless of procedure code (D5110, D5130, D5211, D5213) and one per lower arch, full or partial, regardless of procedure code (D5120, D5140, D5212, D5214), per lifetime. Avesis will review claim payment history for dates of service on and after March 1, 2004 to determine if the Member previously received a denture for the arch.

Benefit Limits Effective April 1, 2012, Health Partners ‘adult

members (age 21 and older) were eligible for the following services only if Avesis approves a BLE request: Crowns and adjunctive services (D2710, D2721, D2740,

D2751, D2791, D2910, D2915, D2920, D2952, D2954, D2980)

Periodontic services (D4210, D4341, D4355, D4910) Endodontic services (D3310, D3320, D3330, D3410, D3421,

D3425, D3426)

Benefit Limits NOTE: The dental benefit changes do not apply to

children under 21 years of age or to adults who reside in a nursing facility, an intermediate care facility for persons with mental retardation (ICF/MR) or an intermediate care facility for persons with other related conditions (ICF/ORC).

EPSDT Services The Early and Periodic Screening, Diagnostic, and

Treatment (EPSDT) programis Medical Assistance's comprehensive and preventive child health program for individuals under the age of 21.

EPSDT includes periodic screening, vision, dental, and hearing services.

EPSDT Services If a Provider is unable to conduct the necessary

EPSDT screens for Members under age 21, the Provider is responsible for making a referral to another Participating Provider to ensure the Member has the necessary EPSDT screening performed.

All relevant medical information, including the results of the EPSDT screening, are to be incorporated into the Member’s primary medical record.

EPSDT Services Based upon the requirements of the EPSDT program,

each Avesis provider office is required to maintain and document the Member recall policies and procedures for all Health Partners and KidzPartners Members.

Additional information on the EPSDT program can be found at www.cms.hhs.gov/Medicaid/epsdt.

CLAIMS

CLAIM SUBMISSIONClaims may be submitted one of three ways:

Through your practice management software using a clearinghouse

On an ADA claim form - please submit to the following address:

Avesis Dental ClaimsPO Box 7777

Phoenix, AZ 85011 – 7777

Utilizing our website at www.avesis.com

CLAIMS FOLLOW UPProviders receive remittance advices detailing claims both paid and denied. If you believe you have not received status on a claim, you may check the status of submitted claims two ways:

You may check claim status on the Avesis website at www.avesis.com.

You may contact our provider services department at (855) 536 - 7764 to check claim status.

CORRECTED CLAIMS Submission

If you are missing information (i.e. tooth number or quadrant number) or you have submitted incorrect information (wrong code, wrong tooth number, etc) you may edit the claim on the Avesis website.

If you wish to submit a corrected claim on an ADA claim form you will need to do the following:

• Write corrected claim on the top of the ADA claim form in blue or black ink. The scanner does not read red ink

• Please do not highlight notes on the claim in blue or green highlighter. The scanner reads these colors as black so what ever they highlight is blacked out.

CLAIMS PAYMENT Electronic Funds Transfer available for all claims

submissions or resubmissions

Check runs WEEKLY

EFT payments deposited weekly

CLEAN CLAIMS processed and adjudicated within 15 business days

CPS transactions completed weekly

Electronic Funds Transfer Agreement

Card Payment Services (CPS) Your office may have received a

communication concerning the partnership between Avesis and Card Payment Services (CPS), to transmit future claims payment transactions via the MasterCard® network.

Frequently Asked Questions are available in the Provider Newsletter and upon request. Please let your Provider Services Representative know if you have any additional questions.

PRIOR AUTHORIZATIONPRE-TREATMENT ESTIMATES

& BENEFIT EXCEPTIONS

Avesis Pre-Treatment Estimate/Prior Approval

Services requiring prior approval are listed in detail in the provider manual

Providers may submit both pre-treatment estimates and requests for benefit exceptions on an ADA claim form to our Phoenix address or via the Avesis website at www.avesis.com with all pertinent clinical information to accompany the request.

Avesis Pre-Treatment Estimate/Prior Approval

Avesis accepts electronic attachments via the Avesis web portal.

Prior authorization and benefit exception requests are processed within 2 business days of the receipt of all required information.

Both the provider and Member will receive a written notice of the approval or denial of the request. Denials of service will contain an explanation as to the reason for the denial.

Requesting a Benefit Limit Exception Avesis will grant benefit limit exceptions to the

dental benefits when one of the following criteria are met: Avesis determines the Member has a serious chronic

systemic illness or other serious health condition and denial of the exception will jeopardize the life of the Member.

Avesis determines the Member has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the rapid, serious deterioration of the health of the recipient.

Requesting a Benefit Limit Exception Continued -

Avesis determines that granting a specific exception is a cost effective alternative.

Avesis determines that granting an exception is necessary in order to comply with Federal law.

Requesting a Benefit Limit Exception In order to request a dental BLE, dentists must

submit the following information to Avesis: An American Dental Association (ADA) claim form

completed in its entirety. Providers must include their NPI number on the claim form. Failure to do so will result in your BLE request being returned to the requesting office.

A completed Avesis Dental BLE request form.

Requesting a Benefit Limit Exception Providers may require a BLE prospectively (prior to

services being rendered) or retrospectively (after services are rendered).

Retrospective BLE requests must be submitted no later than 60 days from the date Avesis denies the claim because the service was originally over the benefit limit.

Retrospective BLE requests received on or after the 61st day from the date of the claim rejection will be denied.

Requesting a Benefit Limit Exception Avesis will respond to prospective BLE requests

within 21 days after the request is received. Avesis will respond to a retrospective BLE request

within 30 days after the request is received. Both the provider and Member will receive a written

notice of the approval or denial of the dental BLE request.

CHART REVIEWS

Avesis Office Visits Avesis conducts office reviews for our dental provider

networks

Your office will be contacted in order for Avesis to schedule a time to come out and perform the onsite visit

In addition to a facility walk through, providers will be furnished a list of charts prior to the visit to have available for review

After the visit, your office will be sent a letter regarding the findings of our review

PROVIDER SERVICES

Services to Providers Avesis is primary for Provider Services

Toll free phones staffed by experienced and knowledgeable representatives from 7am – 7pm EST

State and National professionals involved in professional decisions regarding care and referrals

Services to Providers (Cont.)

Local Avesis representative

Regional meetings and training sessions scheduled for providers

Quarterly Provider Newsletters

On-site assistance in your office when available

Peer to peer interaction for Providers

Other Avenues for Assistance Schedule a conference call

Schedule a web demo

Schedule an onsite visit

Committed to Technology

24/7 Access to information: Web Based

Eligibility verification Claim submission with real time claims

processing Claim status and editing Remittance advice information Pre-treatment Estimate

Interactive Voice Response (IVR) Eligibility Benefits

Committed to Technology

Avesis offers online assistance with website navigation. Providers may access tutorials that show how to create an account, confirm eligibility and submit claims on the Avesis website at http://www.avesis.com/provider_videos.html

Providers may also contact Avesis for a web demonstration and training session by calling (855) 536 – 7764.

THANK YOU

Thank you for your time & attention.

We at Avesis look forward to working with you and your team.