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An Educational Presentation
Presented by: Avesis
Avesis/Wellcare Of GeorgiaMedicaid and Medicare AdvantageDental Providers & Staff
January 2013GA021014_PRO_LTR_ENG State Approved 12042012© WellCare GA_12_12 50244
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Mission Statement
Building long term partnerships to deliver valued, innovative healthcare solutions… one member at a time.
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Who We Are
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
Covering over 4.5 million members throughout the country
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Avesis Dental
Dental Networks
Over 30,000 dentists in 41 States
Experienced Administrator
30 years serving corporate and government clients
Avesis administers Medicaid dental plans in 3 states and Medicare Advantage dental plans in 11 states
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Avesis is National
Executive Offices in Baltimore, Maryland
Operations located in Phoenix, Arizona
Southeast regional office in Atlanta, Georgia
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Points of Contact
Dora WilsonExecutive Vice President/Health Plan [email protected](800) 522-0258 x794
Renee RuggieroAssistant Director of Health Plan Provider [email protected](800) 522-0258 x753
Carolyn WrightManager of Utilization [email protected](800) 522-0258 x294
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Points of Contact
Tommie HowardProvider Services [email protected](800) 522-0258 x756
Cassandra WilliamsProvider Services [email protected](800) 522-0258 x805
Tonya Wilson Provider Services Representative (Medicare Advantage)[email protected]
(800) 522-0258 x715
General Provider Inquiries
(800) 231 0979
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Clinical Professionals
Dr. Fred SharpeChief Dental [email protected]
Dr. Rick CelkoRegional Dental [email protected]
Dr. Mindy BrodaState Dental Director/National Director of UM and Clinical [email protected]
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Avesis Dental Advisory Board
Committee of Georgia licensed Dentists and Avesis staff
Acts in an advisory capacity to WellCare of Georgia and Avesis in all matters pertaining to the Avesis/WellCare of Georgia Dental Programs
Helps to ensure quality communications between the Georgia provider community, Avesis and WellCare of Georgia
Forum for providers to submit recommendations and feedback regarding the programs and their administration
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Eligibility
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Eligibility
It 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.
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Eligibility
You may obtain eligibility verification three ways:
1. Website – This method provides you with information as to whether or not the member is eligible on the date of service and allow you to view the members utilization history. (www.Avesis.com or check the state website (https://www.mmis.ga.gov)
2. Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data. You may call 800-231-0979 to reach the Customer service department.
3. Fax – You may utilize the form found of the following slide for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.
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Fax Eligibility Verification
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Benefits
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Benefits Overview
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 if and only if the Member is notified of and agrees to financial responsibility prior to services being rendered
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Non-Covered Services Disclosure Form
This form is for your protection and the Member pays Usual and Customary Fees
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Benefits Overview
Health Check (under 21) Dental Program
Peachcare for Kids Program
Adult Medicaid and Enhanced Adult Dental Program
Planning for Healthy Babies
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Benefits Overview
•Additional Benefits & Surcharges
•Employees, Retirees & Employers •COBRA
•Benefit Coordinators •Rates
•SHBP Initiatives •SHBP News
•SHBP Publications •Regulations, Policies & Resolutions
•SHBP Performance Center •Contact SHBP
•About SHBP
•Medicaid •Applying for Medicaid
•Georgia Families •Long Term Care
•Planning For Healthy Babies •Medicaid Publications
•Medicaid Quality Reporting •Medicaid & CHIP Redesign
•Additional Resources •PeachCare for Kids
•Pharmacy •Indigent Care Trust Fund
•Georgia Long Term Care Partnership
You are hereHome » Programs » Medicaid » Planning For Healthy Babies » Client Benefits & Services
Client Benefits & Services
Women enrolled in Planning for Healthy Babies® who do not receive Medicaid are eligible for family planning services covered by the Georgia Medicaid program including:In addition to the family planning services listed above, women who give birth to a very low birth weight (VLBW) baby on or after January 1, 2011, and do not receive Medicaid or are losing Medicaid coverage, are eligible for inter-pregnancy care services, which offer:Planning for Healthy Babies
In addition to family planning services, women who give birth to a very low birth weight (VLBW) baby on or after January 1, 2011, and do not receive Medicaid or are losing Medicaid coverage, are eligible for inter-pregnancy care services, which includes a limited dental benefit of :• Two exams per year• Two cleanings per year• X-Rays once a year• Deep gum cleaning
Please refer to the Benefits Grid on Avesis.com for details
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Claims
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Claim Submission
Claims may be submitted one of three ways:
Through your practice management software using a clearinghouse
• The Avesis payer identification number is 86098
On an ADA claim form - please submit to the following address:
Avesis Dental ClaimsPO Box 7777Phoenix, Arizona 85011 – 7777
Utilizing our website at www.avesis.com
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Claims Follow-up
Providers 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 (800) 231-0979 to check claim status
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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 regardless of the method of submission.
• 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
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Avesis Claims Payment
Check runs weekly
CLEAN CLAIMS processed and adjudicated within 15 business days
Payment available through EFT, Paper Checks or through Card Payment Services (CPS) via Master Card account
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Prior AuthorizationPre-treatment Estimates & Benefit Exceptions
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Avesis Prior Approval Requirements
Services requiring prior approval are listed in detail in the provider manual and on the covered benefits schedule.
Providers may submit pre-treatment estimates on an ADA claim form to our Phoenix address or via the Avesis website at www.avesis.com.
Avesis accepts electronic attachments via the Avesis web portal.
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Chart Reviews
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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
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
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Provider Services
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Services to Providers
Avesis is primary for Member and Provider Services
Toll free phones staffed by experienced and knowledgeable representatives from 7am – 7pm EST at 800-231-0979.
State and National professionals involved in professional decisions regarding care and referrals
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
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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
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Thank You For Your TimeQuestions?
We at Avesis look forward to working with you and your team.