Dental Refresher Workshop - Presented by The Department of Social Services & Hewlett Packard Enterprise - Connecticut Medical Assistance Program

Dental Refresher
    Workshop
    Presented by
    The Department of Social Services
    & Hewlett Packard Enterprise

1

Training Topics
  • Provider Enrollment and Re-enrollment
  • Demographic Maintenance
  • Client Eligibility
  • Dental Fee Schedule
  • Prior Authorization
  • Program Limitations
  • Web Claim Submission
  • Frequent Claim Denials
  • Claims Audit Criteria
  • Provider Bulletins
  • Remittance Advice
  • Electronic Messaging
  • Messages Archived
  • Medicaid EHR Incentive Payment Program
  • What’s New
  • Available Resources
  • Questions

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Provider Enrollment and Re-enrollment

 • The Department of Social Services (DSS) allows a majority
    of providers to enroll/re-enroll       on   our   Web    site
    www.ctdssmap.com.

 • A majority of the required information on a re-enrollment
    application is automatically populated      based   on   the
    provider’s previous contract information.

 • Online    re-enrollment cannot be initialized until an
    Application Tracking Number (ATN) is received from the
    Hewlett Packard Enterprise Provider Enrollment Unit.

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Provider Enrollment and Re-enrollment
• Select Provider Enrollment from either the Provider box on
   the left hand side of the home page or from the Provider
   drop-down menu; select Provider Re-Enrollment from the
   Provider drop-down menu.

• Re-enrollment Period: Dental providers are required to re-
   enroll every 2 years.
         •   Re-enrollment via the Enrollment/Re-enrollment Wizard on the
             CMAP Web site, www.ctdssmap.com, is required.

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Provider Enrollment and Re-enrollment

 Re-enrollment Notification and Process:

 • Dental providers will receive a reminder letter when they
    are due for re-enrollment six (6)months prior to the end of
    their current contract (Reference Provider Bulletin 2014-
    52).

 • It is imperative that providers successfully complete
    the re-enrollment application as quickly as possible
    upon receipt of their notice.

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Provider Enrollment and Re-enrollment
 Follow on Documents:
 • Once the enrollment/re-enrollment application is submitted,
    providers are notified of any follow on documents that need
    to be mailed to Hewlett Packard Enterprise’s Enrollment
    Unit.
 • The document requirements vary by provider specialty.
 • The enrollment/re-enrollment application is not considered
    complete until all the required documents have been
    received.
 • Providers with re-enrollment applications that are not fully
    completed by the provider’s re-enrollment due date will
    receive a notice advising they have been dis-enrolled from
    the Connecticut Medical Assistance Program (CMAP).

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Provider Enrollment and Re-enrollment
 Follow on Documents: Providers can access the follow on
 document requirements from www.ctdssmap.com by clicking
 Provider > Provider Matrix > Follow on Document
 Requirement by Provider Type and Specialty.

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Provider Enrollment and Re-enrollment
 Re-enrollment Due Dates:
 • Providers with Secure Web portal access can view their re-
   enrollment due date once logged in.
       Individual providers can view their re-enrollment due date on the
          Home page.
       Organizations can view their re-enrollment due date, as well as the re-
          enrollment due date of their members by accessing the “Maintain
          Organization Members” panel.
 • This feature allows individual providers and organizations to
   better track their re-enrollment due dates prior to receiving their
   notice to re-enroll.

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Provider Enrollment and Re-enrollment

 Performing Providers:

 • Billing   groups need to associate their performing
    providers to the group since performing providers are now
    enrolled/re-enrolled independent of the groups they belong
    to.

 • The    performer would re-enroll according to their re-
    enrollment due date which may be different from the group.

 • The re-enrollment letter will only be sent to one address if
    the performing provider belongs to more than one group.

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Provider Enrollment and Re-enrollment

 • To    check the status of an enrollment/re-enrollment
    application, select “Provider Enrollment Tracking” from
    either the “Provider” submenu or the “Provider” drop-down
    menu.

     – Enter your “ATN” and “Business OR Last Name” and click
       “search.”

          •   In this example, the status      is   waiting   for   additional
              information from the provider.

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Demographic Maintenance
DSS requires providers to update their demographic information
via their secure Web account. Demographic information includes
provider addresses, Electronic Funds Transfer (EFT) and
member of organization maintenance. The main account
administrator must log on to their account and click on the
“Demographic Maintenance” tab. See Chapter 10 of the Provider
Manual for more information.

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Demographic Maintenance – Address
 Updates
  Specify different mailing, payment, service location, and
  enrollment addresses.

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Demographic Maintenance – EFT
 Updates
 The EFT Account panel allows you to add and maintain bank
 accounts into which reimbursements from CMAP will be
 electronically deposited.
 • Click “add”; enter the appropriate information; and click
   “save.”

                      Dough Financial
                      2500 Main Street

                      Willimantic
                      CT   06060 1234

 **This action will place the provider in a pre-notification
 status**
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Demographic Maintenance – Maintain
 Organization Members

 • The Maintain Organization Members panel allows you to:
          •   Search current or historical members using the search button.
          •   Add new members by entering their Organization Member ID
              (NPI) as well as Effective Date.
          •   Separate members by selecting their line and entering an End
              Date.

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Demographic Maintenance – Maintain
Organization Members
 When enrolling or attaching a performing provider
 to a group, the provider must be the same
 specialty as the group that it is being tied to.

     • Example:
     A Dental group with an Endodontist
     Specialty(270) cannot have a Pediatric
     Dentist Specialty (274) attached to it.

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Demographic Maintenance – Maintain
 Organization Members
 Re-enrollment due dates are now visible on the maintain
 organization panel.

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Client Eligibility - Verification
 DSS recommends that providers verify a client’s
 eligibility on the date of service prior to providing
 services.
 To verify a client’s eligibility through the secure Web site
 www.ctdssmap.com – click on the Eligibility tab on the main menu.

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Client Eligibility - Verification

 Search by Service Type Codes
 • Providers have the option to search up to five (5) different
    service type codes. The service type codes allow providers
    to verify the client’s eligibility benefit coverage for specific
    services.

     The first service type code field defaults to 30 – Health
      Benefit Plan Coverage. If the provider searches by that
      default selection, it will return with all the service type
      codes that are covered for the client’s benefit plan.

     The specific service type code for Dental providers is “35”
      for “Dental Care.”

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Client Eligibility - Verification

• Enter enough data to satisfy at least one of the valid search
   combinations; click search.
    When entering a full name as part of your search, a
     middle initial is required if present in the client’s CMAP
     profile.

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Client Eligibility - Verification
Search by Service Type Codes 35 – Dental Care

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Client Eligibility - Verification
 HUSKY B client eligibility search response

 • HUSKY B copay amounts will not show on the eligibility screen,
    provider should refer to the dental fee schedule.
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Client Eligibility - Third Party Liability
 (TPL) Update

 To correct or update Third Party Liability (TPL)
 information:
 You must obtain a TPL form from the following options:

      • Print out form located on Web site at www.ctdssmap.com under
        Information → Publications → Forms →Third Party
        Liability Forms→ TPL Information Form.

      • Call Health Management System, Inc. (HMS) 1-866-277-4271.
        HMS staff will mail or fax the form to the provider.

      • E-mail request to ctinsurance@hms.com and the form will be e-
        mailed back to provider.

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Client Eligibility - TPL Update

 Submit completed forms via:

    •   Mail to:
             Health Management Systems, Inc.
             Attn: CT Insurance Verification Unit
               5615 High Point Dr.
               Suite 100
               Irving, Texas 75038

    •   Fax to HMS with HIPAA compliant cover letter to 214-560-3932.

    •   Scan completed forms and submit through e-mail to
        ctinsurance@hms.com.

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Dental Fee Schedule

 • Select Provider Fee Schedule Download from Provider menu.
 • Click “I accept” to the Connecticut Provider Fee Schedule End
    User License Agreement page.
 • Provider Fee Schedules are listed by provider type. Choose
    Dental by clicking on the CSV link.

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Dental Fee Schedule
 • Provider Fee Schedules are listed by provider type. Choose
    Dental by clicking on the CSV link.

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Dental Fee Schedule
   Dental Fee Schedule dated 9/1/2014, Last Updated on
   05/02/2016.

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Dental Fee Schedule
Dental Fee Schedule Footer

• PR means Post Authorization Review is required to be obtained from
   Connecticut Dental Health Partnership(CTDHP) AFTER the service has been
   performed.

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Dental Fee Schedule
• PA means Prior Authorization is required to be obtained from
   CTDHP BEFORE the service is performed.
• 21 means that Prior Authorization is required for patients 21 years
   of age and older.

• PA means that Prior Authorization is required for all patients.

• Providers can access the dental fee schedule at
   www.ctdssmap.com to determine which procedure codes
   require PA or PR.

• Providers should refer to the CTDHP Web site www.ctdhp.com
   and access the provider manual to determine if a procedure
   complies with the Medical Services Policy.

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Prior Authorization

 • Electronic prior authorization or post procedure review
    requests may be submitted electronically via the
    www.ctdhp.com provider Web portal.
     To upload a PA/PR request, follow the steps outlined
      below:
               1. Access the www.ctdhp.com Web site and click on
               "Provider Partners.”
               2. Enter your Billing NPI and Tax ID numbers in the
               appropriate boxes and click on “Login."
               3. A new screen will appear, click on "Prior
               Authorization Upload."
               4. Follow instructions for prior authorization or post
               procedure review requests.

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Prior Authorization

 • Hard copy submissions for the non-orthodontic services
    that require PA or PR should be submitted to:
        CT Medicaid Prior-Authorizations
        C/O Dental Benefit Management, Inc. / BeneCare
        P.O. Box 40109
        Philadelphia, PA 19106-0109

 • Hard copy PA requests for orthodontic services should be
    submitted to:
        Orthodontic Case Review
        C/O BeneCare Dental Plans
        195 Scott Swamp Road, Suite 101
        Farmington, CT 06032

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Prior Authorization

 • For any questions regarding PAs or to request an emergency
    PA, call CTDHP Provider Relations and Services at:
     1-888-445-6665 Monday through Friday, 8 a.m. to 5
      p.m. (EST), excluding holidays

 * Please Note: Do not submit any PAs or PRs to
  Hewlett Packard Enterprise or DSS, the PAs and PRs
  will be returned to your office.

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Prior Authorization

 • Allow fifteen (15) business days for the review, processing of
    prior authorization and post procedure review requests.

 • CTDHP will enter the information for the approved PAs and
    PRs in Hewlett Packard Enterprise’s system.
     Denied PA/PR requests will not be entered; however, the
      provider will be informed via a written response.

 • PA approval status may be verified via the CT Medical
    Assistance Program Web site at www.ctdssmap.com.
     The Prior Authorization (PA) Search allows providers to
      see if the PA or PR has been entered into the system prior
      to submitting their claims.

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Prior Authorization Inquiry
 • On the provider secure Web site www.ctdssmap.com, under
    “prior authorization” select “prior authorization search”.
 • Enter a client ID and click search to bring up prior
    authorizations for a specific client.

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Prior Authorization Inquiry
 PA Inquiry result

 • You can see the procedure code that was approved,
    authorized units/dollars, authorized effective/end dates,
    used units/dollars and available units/dollars.
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Program Limitations
 Provider Bulletin 2012-38 “ Change of Dental Benefit
  Assignment by Dental Provider to Benefit Assignment
  by Client.”

 • The benefit limitations for services delivered to all clients
    changed from a provider based benefit assignment to a
    client based benefit assignment which mirrors commercial
    dental plan reimbursement. This took effect on November 1,
    2012 for all clients.

 • All dental providers who deliver services to clients should
    check to ensure that each client is eligible to receive dental
    services by verifying the client’s eligibility status and
    dental history before performing any treatment on a client.

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Program Limitations
 • To verify when a procedure was last performed on a client,
    go to the www.CTDHP.com Web site and click on the link on
    the left hand side of the Home Page labeled "Provider
    Partners" then click on “Provider Login”.
 1) Choose the link labeled “Client Inquiry.”
 2) Enter the client’s Medicaid ID number and date of birth and
      click “Submit.”
 3) The screen will return the client’s current eligibility status
      for the date of the inquiry as well as a listing of all historical
      dental procedures performed on file for this client. The
      procedures reported go back to 2008.

 * It is important to ask clients about any recent dental visits
 as the claims history does not include claims yet to be
 submitted for services recently performed.

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Web Claim Inquiry
  • From the secure Web portal at www.ctdssmap.com, select
    “claim inquiry” from the “Claims” menu to view claims
    processed regardless of the submission method
  • Search by:
      Internal Control Number (ICN)
      Client ID and date of service (no greater range than 93
       days)
      Pending claims

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Web Claim Submission
 Dental claims can be submitted through the secure Web site
 by signing into www.ctdssmap.com.

  Once on the secure site, select Dental from the claims
      drop-down menu.

 Claim types that can be submitted through the secure Web
 site www.ctdssmap.com:

 • Primary and Secondary/Third Party Liability (TPL) claims.
 • Re-submission of previously denied claims.
 • Adjustments of previously paid claims if within timely filing.
 • Recoup/Void a claim at any time regardless of timely filing.

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Web Claim Submission

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Web Claim Submission

 • If the provider is billing for a behavior management
    procedure code (D9920) along with other dental services,
    they must bill the related diagnosis code to the behavior
    management service in the diagnosis field.
 • No other dental services require a diagnosis code to be
    entered on the claim.

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Web Claim Submission with TPL
Medicaid is the Payer of last resort. The three digit Carrier Code of the
Other Insurance (OI) is required to be submitted on the claim when OI is
primary.
   –The three digit code can be found on the client eligibility verification
    screen under TPL (Third Party Liability) Information

   –It can also be found on the claim submission screen under the TPL
    panel in the “Client Carriers” field.

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Web Claim Submission with TPL
• TPL payment of $100.00 from carrier code 060 with a paid date of
  06/01/2016.

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Web Claim Submission
Once you hit the submit button, the claim results are
immediate.

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Web Claim Submission

Web Claim function buttons

Paid claim

Denied claim

Suspended claim

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Frequent Claim Denials
   EOB Code 9992        “Payment Amount Reflects Tooth Surface
   Pricing”

• A good reference for these denials is Provider Bulletin 2014-62
 “Update to the Medicaid Dental Services Fee Schedule and
 Policy.”
   The bulletin informs dental providers that CMAP does not
    reimburse for the restoration of separate surfaces when treatment
    is performed on a single tooth by the same provider (on the same
    tooth, for the same provider). Dental providers will be reimbursed
    for the total number of surfaces restored on a single tooth per one
    year period for each provider.
   In scenarios where the client fractures the tooth within a year of
    the restoration and returns to get the tooth fixed, the provider can
    request authorization for the service through CTDHP to receive the
    full reimbursement amount.

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Frequent Claim Denials
   EOB Code 9992          “Payment Amount Reflects Tooth Surface
   Pricing” (Continued)

   Example: A provider was paid for restoration on tooth #19 for
    surfaces M (Mesial) and O (Occlusal). The same provider submits
    a second claim for the same client within one year from the
    previous date of service for restoration on the same tooth for
    surfaces D (Distal) and O (Occlusal). The second claim will not pay
    for a second two surface restoration but will pay the difference
    between the two surface and the three surface restoration and
    post Explanation of Benefit (EOB) code 9992 - Payment Amount
    Reflects Tooth Surface Pricing at the detail.
   For restorations done on a tooth for a specific date of service, the
    provider should submit the claim with the appropriate code (D2140
    – D2394) for the service provided as one detail rather than
    submitting them on separate details for the individual surfaces.

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Frequent Claim Denials
    EOB Code 261         “Tooth Number Missing”
    EOB Code 262         “Tooth Number Invalid”
    EOB Code 4211        “Tooth Number/Procedure Code Combination
                          Invalid”

• A good reference for these denials is Provider Bulletin 2009-25
  “Tooth Numbers to be Used in Conjunction with Specified
  Procedure Codes” and Provider Bulletin 2009-57 “Correction to
  Bulletin 2009-25 Updates to Requirements for Dental Claims
  Submission.”
    It informs dental providers about the proper tooth numbers to use
     when submitting claims which involve CDT codes that require tooth
     numbers and/or letters.
    This bulletin also defines the proper format to use when submitting
     claims which involve supernumerary teeth.
    Certain procedures have age restrictions on specified codes and
     this bulletin informs dental providers of the age limitations that are
     included on the Medicaid Dental Fee schedule.
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Claims Audit Criteria
In accordance with subdivision (11) of subsection (d) of section
17b-99 of the Connecticut General Statutes, audit protocols have
been published on the Department of Social Services’ Web site.
An introduction to audit protocols and an overview of the audit
process can be found at: http://www.ct.gov/dss/auditprotocols.
Links to audit protocols organized by provider type are located on
the lower section of this Web page.

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Claims Audit Criteria
 Dental audit protocols list the most common reasons why a
 provider’s claims may be audited.

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Provider Bulletins
Provider Bulletins
• Access the Publications page by selecting Publications from
    either the Information box on the left hand side of the home
    page (www.ctdssmap.com) or from the Information drop-
    down menu.

• Bulletin Search allows you to search for specific bulletins (by
    year, number, or title) as well as for all bulletins relevant to
    your provider type.
    When searching by provider title, you can search by any
        word as long as that word is in the title of the bulletin.

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Provider Bulletins
Provider Bulletins – Searching by Year and Type

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Provider Bulletins
Recent Dental Provider Bulletin:
• Provider Bulletin 2016-27 “ Changes in the Children’s
    Dental Fee Schedule Reimbursement Rate”
           Effective for dates of service July 1, 2016 and forward, the fees for
            dental services provided to children will be reduced by 5%. The rates
            for dental services provided to adults are not affected and will remain at
            the current reimbursement level. The action reflects the adjustments
            to the State’s biennial budget.
           Two separate dental fee schedules will be posted on the
            www.ctdssmap.com Web site – one for the pediatric reimbursement
            rates (for clients under the age of 21), and the second for the adult
            reimbursement rates (for clients age 21 and above).
           The new pediatric rates will not be in the claims processing system on
            July 1, 2016. Hewlett Packard Enterprise will continue to process the
            claims using the existing rates till the system has been updated with
            the new rates.
           At a later date (to be determined), claims for pediatric clients submitted
            for dates of service July 1, 2016 and forward will be reprocessed to pay
            the rates effective as of July 1, 2016.

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Provider Bulletins
Recent Dental Provider Bulletin:
• Provider Bulletin 2016-27 “ Changes in the Children’s
    Dental Fee Schedule Reimbursement Rate” (Continued)
           Hewlett Packard Enterprise will announce the claims cycle date for the
            retroactive reprocessing through the “Important Message” which is
            posted on the home page of the www.ctdssmap.com Web site.
           The notification with regards to the reprocessing will also appear on the
            first page of the Remittance Advice (RA) as a Banner message. The
            Banner messages are also posted on the www.ctdssmap.com Web site
            and can be accessed from the home page by clicking on “RA Banner
            Announcements” link under “Information”.
           The reprocessing will result in Accounts Receivable(s) for the provider
            which will be listed under the Financial Transactions section of the
            Remittance Advice.

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Remittance Advice
   Financial Transaction

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Remittance Advice
      Financial Transaction Reason Codes
      The last page of the Remittance Advice lists the description
         of the Accounts Receivable Reason Codes

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Remittance Advice - Summary

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Electronic Messaging
• DSS and Hewlett Packard Enterprise now use electronic
  messaging to distribute:
     Provider bulletins and policy transmittals.
     Workshop invitations.
     Program updates and reminders.
     Important Messages.

• Any office personnel can subscribe to receive program
  information via email

• You can update your subscription list or unsubscribe at any
  time.

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Electronic Messaging
• Subscriptions can be accessed from the www.ctdssmap.com
  Web site.
    Select Provider > E-mail Subscription from the drop-down
     menu.

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Messages Archived
DSS and Hewlett Packard Enterprise have started archiving RA
Banner and Important Messages on the www.ctdssmap.com Web
site. To access archived messages, providers need to access the
Messages Archived page by selecting Messages Archived from
the Information drop-down menu on the home page. RA Banner
and Important Messages dated January 1, 2014 and forward are
saved on the Web site and are available for review.

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Medicaid EHR Incentive Payment Program
The Electronic Health Records (EHR) incentive program was
established by the Health Information Technology for Economic
and Clinical Health (HITECH) Act of the American Recovery &
Reinvestment Act of 2009. This program aims to transform the
nation’s health care system and improve the quality, safety and
efficiency of patient health care through the use of electronic
health records.

EHR Incentive Program Eligibility
  The following eligible professionals may participate in Connecticut
  Medicaid’s EHR incentive program:
     •   Physicians
     •   Nurse practitioners
     •   Certified nurse-midwives
     •   Dentists

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Medicaid EHR Incentive Payment Program

• For those eligible providers interested in the CT Medicaid EHR
  Incentive Payment Program, please go to www.ctdssmap.com, under
  Provider > EHR Incentive Program.
• 2016 is the last year an eligible provider can start in the Medicaid
  EHR Incentive Payment Program.
• You may also contact us via a toll free Provider Assistance line or
  email address with any questions:
        1-855-313-6638
        ctmedicaid-ehr@hpe.com

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What’s New?
• Per Provider Bulletin 2016-31 “Elimination of Paper Claims
 Notification”, DSS has mandated that as of October 1, 2016
 paper claims will no longer be accepted for reimbursement.
• Paper claims submitted to Hewlett Packard Enterprise on or after
  October 1, 2016 will be returned to the provider.
•   Several on-line resources are available to providers to assist with
    this transition:
        •   Provider Manuals
                 Chapter 5 – Claim Submission Information
                 Chapter 8 – Provider Specific Claim Submission
                      Instructions
                 Chapter 11 – Other Insurance and Medicare Billing
                      Guides
       Internet Claim Submission FAQ
        •

• Excluded from this mandate are provider claims that are
  submitted to Hewlett Packard Enterprise for special handling, such
  as timely filing overrides and Out Of State (OOS) Providers.

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Training Session Wrap Up
Where to go for more information www.ctdssmap.com
    • Important Messages and Provider Bulletins
CTDHP Provider Relations and Network Support will assist
  with PA, claim history and Provider Enrollment: Monday
  through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays.
    • 1-888-445-6665
Client Services to assist clients in finding dentist.
    • 1-855-283-3682
Hewlett Packard Enterprise Provider Assistance Center to
  assist with claims: Monday through Friday, 8 a.m. to 5 p.m.
  (EST), excluding holidays.
    • 1-800-842-8440
    • 1-800-688-0503 (EDI Help Desk)

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Time for Questions

                      Questions & Answers

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