A New Day For Oral Health In Virginia

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A New Day For Oral Health In Virginia
Spring 2008 Provider Training Seminars April 29
30, 2008

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Agenda

• Welcome and Introductions
• Review of Teleconference Instructions
• Retrospective Utilization Review and Audit
  Process
• Treating Special Needs Enrollees
• National Provider Identifier (NPI)
• Aged Claims and Timely Filing
• News and Updates
• Check and Remittance Printing
• Q A

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Training Objectives

• Provide insight into the importance of
  retrospective utilization review and its
  financial impact on the SFC program.
• Familiarize providers with available tools and
  resources for treating enrollees with special
  needs.
• Assist providers in understanding the
  requirements for conducting business with the SFC
  program as it relates to the NPI.
• Present updates regarding the latest changes to
  the program.

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Retrospective Utilization Review andAudit
Process
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Utilization Review Goal

• Ensure the oral health of members
• Ensure members, the Commonwealth and taxpayers
  are protected from inappropriate use of limited
  Federal and State funds
• Ensure limited resources are utilized for
  medically necessary treatment that meets the
  accepted standard of care.

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Utilization Review Triggers

• Variance of code usage compared to peers within
  the market
• Multiple surface restorations
• Utilization of single surface posterior
  composites compared to utilization of sealants
• Age appropriate code usage
• Number of services per member on a single date of
  service
• Multiple services in multiple quadrants on the
  same date of service

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Sample of Utilization Review Reports

• Benchmark Report
• Standard Deviation Report

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Benchmark Report
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Standard Deviation Report
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Audit Process

• Member specific documentation request is mailed
  to the provider.
• Documentation requested includes, but is not
  limited too
• Treatment notes
• Treatment plan
• Medical History
• Signed Consent
• Diagnostic Quality Radiographs
• Minimum request will be for 10 identified members
• Fed-Ex overnight envelope will be included
• Due date will be three weeks from date of letter

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Audit Process (cont)

• Clinical staff review all submitted
  documentation.
• Dorals Dental Director will make all clinical
  decisions.
• Audit Results will direct the next steps in the
  process. These steps may include, but are not
  limited too
• Behavior Modification Letter
• Re-audit
• Recoupment
• Review by Doral USA Peer Review Committee
• Review by Dorals Virginia Peer Review Committee
• Referral to the Department of Medical Assistance
  Services (DMAS)
• Referral to the appropriate Government agency
  with DMAS approval
• Recommendation to DMAS for Termination from the
  network

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Reasons for Possible Actions

• Upcoding
• Overstatement of services
• Documentation does not support medical necessity
  of billed service
• Inappropriate use of American Dental Association
  CDT-2007/2008 code
• Billing for services not supported in
  documentation
• Unbundling of services
• Quality of care

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Guidelines forUtilization Review Decisions

• Clinical criteria as published in the VA SFC
  Office Reference Manual
• American Dental Association Current Dental
  Terminology 2007/2008
• Recommendations of the following associations
• American Dental Association (ADA)
• American Academy of Pediatric Dentistry (AAPD)
• American Academy of Periodontics (AAP)
• American Academy of Oral Maxillofacial Surgeons
  (AAOMS)

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TREATING SPECIAL NEEDS ENROLLEES
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Developmental Disabilities and Oral Health

• More than 955,626 Virginians are living with one
  or more disabilities.
• This represents 14 of the population.

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Developmental Disabilities and Oral Health

• To achieve and maintain good oral health, people
  with mild or moderate developmental disabilities
  often require a special approach to dental care.
• With some adaptation of the skills dental
  professionals use every day, most people with
  special needs can be treated successfully in the
  general practice setting.

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Developmental Disabilities and Oral Health

• The series of publications, Practical Oral Care
  for People With Developmental Disabilities,
  equips dental professionals in the community with
  the basic information needed to deliver quality
  oral health care to people with special needs.
• The publications present an overview of physical,
  mental, and behavioral challenges common in
  patients with autism, Down syndrome, cerebral
  palsy, and mental retardation and offer
  strategies for providing oral care.
• Also available is a guide for caregivers that
  explains home-based oral hygiene for the family
  member or client with special needs and a
  publication on safe wheelchair transfer.

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Free CEUs 2 Credit Hours

• A two-credit-hour continuing education test for
  dentists and dental hygienists completes the
  series.
• To receive two hours of continuing education
  credit, you must successfully complete the test
  provided by the National Institute of Dental and
  Craniofacial Research (NIDCR). 
• You will be able to print a certificate of
  completion to submit to the State dental board
  and/or keep on file. 
• There is no fee for this continuing education
  activity.
• For more information, please refer to your
  training material packet or visit
• http//www.nidcr.nih.gov/HealthInformation/Diseas
  esAndConditions/DevelopmentalDisabilitiesAndOralHe
  alth/Introduction.htm

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NATIONAL PROVIDER IDENTIFIER(NPI)
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National Provider Identifier (NPI)

• Providers should continue to prepare for
  transition to use of the NPI and full NPI
  Compliance effective May 23, 2008.
• Effective April 1, 2008, Doral began requiring
  NPI, National Provider Identification Number, on
  electronic and paper transactions.
• Claims submitted without an NPI number are
  denied.
• On May 1, 2008, the automated voice response
  system will require that you enter your NPI and
  the last four digits of your Tax Identification
  Number or your User Identification Number,
  previously referred to as Location Identification
  Number and the last four digits of your Tax
  Identification Number.

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How Many NPIs are Needed?

• Doral requires
• Each provider to have a Type 1 (Individual) NPI
  number.
• Every organization to have a Type 2
  (Organization) NPI number
• Organization health care providers are
  corporations or partnerships or other types of
  businesses that are considered separate from an
  individual by the State in which they exist.

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Use of NPI on ADA Claim Forms

• 2006 ADA Claim Form
• Providers are encouraged to use the 2006 ADA
  form.
• Field 49 on the 2006 ADA Claim Form
• A Type 2 NPI is entered when the claim is being
  submitted by an incorporated individual, group or
  similar legally recognized entity.
• Unincorporated practices may enter the individual
  practitioners Type 1 NPI.
• Field 54 on the 2006 ADA Claim Form
• Enter the treating dentists Type 1 Individual
  Provider NPI.

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CLAIMS
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Aged Claims and Timely Filing

• Please remember to review your aged claims on a
  regular basis.
• Timely bookkeeping is important and may prevent
  claims from being denied due to untimely filing
• Providers should follow-up with Doral regarding
  any claims outstanding greater than 45 days
• All initial claims for payment must be received
  by Doral within 180 days from the date of service
• Claim status can be checked by
• Reviewing your printed remittance statements, or
• Visiting Dorals website
• www.doralusa.com
• Or
• by calling Doral at
• 1-888-912-3456

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NEWS AND UPDATES
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Check and Remittance Printing

• During the month of May, your remittances will
  have a new appearance.
• Doral will manage the printing and mailing of its
  provider checks and remittances through a
  specialized vendor Cathedral Corporation.
• Cathedral Corporation uses state-of-the-art
  printing techniques that will produce a quality,
  easy-to-read product.
• There is no change to the claims process. The
  claims payment cycle will remain the same.

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Contact Information

• Doral Smiles For Children Staff
• Cheryl Harris
• Project Director
• Direct Line [phone]
• Fax [phone]
• Email cpharris_at_doralusa.com
• Bridget Hengle
• Provider Relations Representative
• Direct Line [phone]
• Fax [phone]
• Email bhengle_at_doralusa.com
• Kristen Gilliam
• Outreach Coordinator
• Direct Line [phone]
• Fax [phone]
• Email kfgilliam_at_doralusa.com

• DMAS Smiles For Children Staff
• Sandra Brown, MSW
• Dental Program Manager
• Direct Line [phone]
• Fax [phone]
• Email sandra.brown_at_dmas.virginia.gov
• Lisa Bilik
• Dental Contract Monitor
• Direct Line [phone]
• Fax [phone]
• Email lisa.bilik_at_dmas.virginia.gov
• Dr. Marjorie Chema
• Dental Consultant
• Direct Line [phone]
• Fax [phone]
• Email marjorie.chema_at_dmas.virginia.gov

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Thank You!