MEDICAID DENTAL PROGRAM

Policy Review

What is Medicaid?

Wyoming Medicaid is a joint federal and state government program that pays for medical and dental care for low income and medically needy individuals and families.

Wyoming Medicaid benefit expenditures generally receive 50 percent Federal match (FMAP).

Medicaid provides medical assistance for low-income and medically vulnerable citizens. There are currently four major categories of eligibility: Children, Pregnant Women, Family Care Adults, and Aged, Blind or Disabled (ABD).

Medicaid Dental

• Children’s program is mandatory by the federal government and covers all services needed to prevent and treat dental diseases and restore function.

• Adult program is optional and can be limited to basic services as determined by each state.

• Expansion of the adult coverage range is optional and must be passed by the legislature and governor for each state.

State Duties vs. Fiscal Agent Duties

• The Division of Healthcare Financing administers the Medicaid program. They are responsible for financial management, developing policy, establishing benefit limitations, payment methodologies, and fees, and performing utilization reviews.

• Medicaid Dental Manager- April Burton

State Duties vs. Fiscal Agent Duties

• The Fiscal Agent (Xerox Healthcare Solutions) processes all claims and adjustments. They also answer provider inquiries regarding claims status, payments, client eligibility, known third party payers and provide onsite visits to train and assist your office staff on Medicaid billing procedures or to resolve claims payment issues.

• Xerox Dental Supervisor/Field Rep- Amy Reyes

Who reviews dental policies?

The Medicaid Dental Manager is responsible for presenting new policies, codes, and fees to the Medicaid Dental Advisory Group (DAG) for consideration.

The DAG is made up of 6 dentists and Department of Health and Fiscal Agent employees.

The DAG collectively reviews new or changes to existing policies for compliance with industry standards.

What does the DAG do?

When would the DAG review a policy?

1. New ADA codes

2. Provider requested fee increase

3. Data shows outliers in billed charges

4. Clinical appeals from providers

The DAG members also provide professional advice and expertise on current acceptable dental practices.

How many dentists participate with

WY Medicaid? • In 2016, 241 of the 307 licensed, practicing

dentists in Wyoming are enrolled as Medicaid providers

• WY ranks in the top 10 for provider participation and fee reimbursement in the nation. 79% of licensed dentists are MC providers. The national average is (40-50%)

What are my requirements as a

provider? • Bill claims timely, within 12 months to avoid timely filing

denials

• Retain adequate records

• Inform clients, in writing, if a service is not covered or if the client has used their benefit limits

• Report suspected abuse or fraud by another provider or eligible client (section 4.9.1)

• Check client eligibility prior to rendering services

• Review and understand all policies contained in the provider manual

Dental Manual Updates

• All providers are responsible for using the most updated version of the Medicaid Dental Manual

• The manual is available on the Web Portal and can be searched using the Ctrl F option

• The manual is updated quarterly, online

* Janunary 1st

* April 1st

* July 1st

* October 1st

What is Program Integrity?

Medicaid Program Integrity Unit is in place to do the following:

1. Review of claims submitted for payment

2. Review of dental records related to covered services

3. On-site review of dental records and client interviews

4. Case management oversight

5. Recovery of overpayments or payments made in error based on policies

What is expected from Program

Integrity? • Each employee in the provider office are

informed of Medicaid rules and policies

• Records are kept accurately on each client

• Access to client records as requested

• Access to financial records of reimbursement from Medicaid

• Office policies are enforced the same for all types of patients EX. Medicaid, Cash pay, Traditional insurance

What is required in the records?

• A patient’s dental records must contain the following information and be typed or legibly hand written:

*Name on each page of the record

*Diagnosis of disease/conditions and history

*Treatment Plan

*All services rendered with:

>Tooth Numbers

>Surfaces

>Quantities

>Medications and dosages

>Observed conditions & progress at each visit

>Total treatment minutes if codes are used that are

reimbursed at 15 minute increments

Referral of Suspected Fraud/Abuse

• Fraud ▫ “An intentional deception or misrepresentation made

by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person”

• Abuse ▫ “Provider practices that are inconsistent with sound

fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare”

Referral of Suspected Fraud/Abuse

• Provider should notify the Program Integrity Unit in writing if fraud or abuse is suspected

▫ Use referral form from manual (4.9.1)

▫ Call 1-855-846-2563

• Provider is responsible for ensuring all employees are informed of rules and regulations pertaining to Medicaid

Client Eligibility

• Determined through Customer Service Center (CSC) 1-855-294-2127 • Not determined through Xerox • Different benefit plans- some cover dental and some

do not • Adults are issued eligibility month to

month/children for a year • If a client is not eligible, it is THEIR responsibility to

call the CSC to update their coverage. • Once a client has renewed it can take a few weeks to

get the renewal approved and the system updated. Any claims that come into Xerox will be denied and not payable if the client was not updated in the system yet.

Provider Responsibilities-Accepting

Clients • Accept client as a Medicaid client upon 1st visit if

the provider is aware of the client’s Medicaid coverage

• Check eligibility prior to rendering services

• Provider may decide not to further treat the client as a Medicaid client. If this occurs, provider must advise the client of this fact in writing before rendering treatment

Provider Responsibilities-Clients

Without Medicaid Cards

▫ Provider may require the client to reschedule until a card can be presented

▫ Provider may see the client, verifying eligibility by using name, dob and/or social security number

▫ Provider may require the client to pay in advance for services. If the client produces a card at a later date and the provider agrees to accept the client as a Medicaid client, the provider must refund the entire amount paid by the client prior to billing Medicaid

▫ If a client fails to notify a provider of Medicaid eligibility and is billed as a private-pay patient, the client is responsible for the bill unless the provider agrees to submit a claim to Medicaid.

Provider Responsibilities-Medical

Necessity • Medicaid will pay only for medical/dental

services that are medically necessary

• Medically necessary means the service is required to:

▫ Diagnose

▫ Treat

▫ Cure

▫ Prevent an illness

Provider Responsibilities-Medical

Necessity • Additionally, the service must be:

▫ Consistent with the diagnosis and treatment of the patient’s condition

▫ In accordance with standards of good medical/dental practice

▫ Required to meet the dental needs of the patient and not the convenience of the patient or doctor

▫ Performed in the least costly setting required by the patient’s condition

Billing of Deliverables

• Federal guidelines state that a service cannot be billed to Medicaid until it is completed.

• When billing for a deliverable (crowns, bridges, retainers, dentures) the provider must bill these procedures on the date of delivery.

• If these codes have been billed on the prep date, the provider is responsible for voiding their claim and re-billing it on the seat date prior to the 12 month timely filing deadline.

Limitations • Fillings- 1/18 months per tooth • Sealants- 1/18 months per tooth and not on the same day

as a filling; ages 0-20 • Crowns- only ages 14-20 • Implant/Bridge- 1/lifetime and only with a Prior

Authorization (PA #) • Dentures/Partials- 1/lifetime-adults, as needed for

children NOTE: It is the provider’s responsibility to check these

limitations PRIOR to rendering these services. If your claim denies due to the benefit already being used, YOU MAY NOT BILL THE CLIENT unless you informed them, in writing, of the charges they may incur.

Limitations

• If the client is in need of a procedure, and the limitation has been used, the client has 3 options:

1. Return to the provider who did the procedure for repair/replacement at no charge to the client or Medicaid

2. Wait until the time limitation is up to have the procedure done

3. Agree to pay for the procedure- this should be in writing prior to rendering the service

Severe Malocclusion Program

• The SMP is the orthodontic program for Medicaid

• Clients can be referred to an orthodontist if there malocclusion appear to meet the set guidelines

• Clients go through an approval process before ortho can be started

• Only clients who have poor malocclusions that affect function EX. Speaking, Chewing, Breathing, will be approved

EHR Incentive payments

• The Medicaid Electronic Health Care Record (EHR) Incentive Program provides incentive payments to eligible professionals as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology

• Provider must see a 30% volume of Medicaid patients within their office and be using a certified EHR system

• Year one- $21,250 per doctor

• Year 2-6- $8,500 per doctor

• Contact- Ruth Friess 307-777-7493