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DQ DIGEST TENNCARE
Spring | 2019 | Volume 2
In This Issue…
Clinical Corner 1
TennCare Appeals 2 Process
ORM Updates 2
Contact Information 3
In Your Clinical Corner… Welcome to our early summer newsletter and updates on progress in attaining our common goals.
Recently most of you will have received a well-deserved additional compensation and we are extremely pleased to provide this to those offices whose history of claims has been aligned with our clear goals of maximizing preventive services. In all our communications, including road shows, written communications, and interpersonal conversations our message has been consistent and clear.
Specifically, that the providers and offices which successfully deliver more preventive services are going to be the future of the network, and most closely aligned with TennCare objectives and DentaQuest mission and goals.
The amounts of the additional dollars varied from office to office, based on frequency of specific procedure codes, including procedures such as sealants, and SDF.
Peer reviewed literature, DentaQuest mission, and the ADA position are all aligned, that we cannot “treat” all the existing pathology or new presentation of pathology; rather we must rededicate to preventing dental disease and these additional funds are aligned with that goal.
Finally, I am pleased to share that Dr. Walter Owens has recently joined DentaQuest. Dr. Owens is well known and respected throughout Tennessee and will be a valuable resource to help DentaQuest attain our goals.
Dr. Brent Martin
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TennCare Appeals Process How to File Appeals
1. Preservice appeals are not REVIEWED by TennCare if the provider completes them and does not submit a signed member consent form.
2. Only appeal cases that are truly needed based on clinical/medical necessity
Pre-Service Appeals
Who Can File a Pre-Service Appeal? The provider on behalf of the enrollee (with written permission) member consent form must be included with submission to TennCare or appeal will not be processed; A guardian on behalf of the enrollee; or the enrollee themselves
How is an appeal filed? Appeals must be filed to TennCare Solutions within 60 days of receipt of the denial from DentaQuest
Appeals can be filed in any of the following ways Mail: TennCare Solutions Unit P.O. Box 000593 Nashville, TN 37202-0593 Phone: (800) 878-3192 Fax: (888) 345-5575
Only the member will be notified of the determination by TennCare Solutions
However, if TennCare Solutions requests a redetermination from DentaQuest a new PDL will be sent to the provider office.
Do not file pre-service member appeals to DentaQuest or on the DentaQuest portal these must be mailed or faxed directly to TennCare Solutions
Office Reference Manual Updated Sections This Quarter The sections of the ORM listed below have received edits, updates, and/or changes during April, May, or June of 2019. Please take this opportunity to review these sections to stay current on your Office Reference Manual. ECF CHOICES
Sections 3.03 TennCare
Sections 15.14
Benefit Tables Benefit limitations have changed for the following codes:
• D0210 • D0330 • D0367 • D1351 • D1352 • D1353 • D1575
Post-Service Appeals
Who Can File a Post-Service Appeal? Only the provider can file a provider appeal;
How is an appeal filed? Appeals must be filed within 60 days of the original determination
Appeals can be filed in any of the following ways Mail: DentaQuest – Provider Appeals PO Box 2906 Milwaukee, WI 53201-2906 Most efficient is submission via the portal or email Email: [email protected]
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Fax: (262) 834-3452 Successful appeals will be automatically approved
Contact Information
Provider Service • TennCare: 855.418.1623
-Press 1 Automated Eligibility (via IVR system -Press 2 Benefits, Eligibility and History -Press 3 Claims and Payment Options
• Credentialing Hotline: 800.233.1468
Department Emails • Electronic Claims Setup and Questions –
• Claims Payment Questions – [email protected]
• Eligibility or Benefit Questions – [email protected]
Utilization Review • 888.294.9650
Provider Web Questions • 888.560.8135 • www.dentaquest.com
Corporate • Main Corporate: 800.417.7140