A New Day For Oral Health In Virginia
Tooth Talk
December 12, 2007
Smiles For Children Program
An Overview
Who’s Eligible and How to Apply?
 To participate in Smiles For Children (SFC), recipients must first be
eligible for Medicaid, FAMIS or FAMIS Plus.
 Once eligible, recipients are automatically enrolled in the SFC program and
receive a Member Handbook.
 Recipients do not receive a SFC ID card. Recipients may use:
 Commonwealth of Virginia (blue and white) plastic identification
 MCO identification card
 For questions regarding Medicaid eligibility, recipients should:
 Visit their local Department of Social Services
 For questions regarding FAMIS or FAMIS Plus eligibility, recipients should:
 Go online and visit: www.famis.org; or
 Call 1-866-87FAMIS (1-866-873-2647)
Enrollee Eligibility
 Doral uses the 12-digit Medicaid ID number as the
enrollee ID Number.
 Eligibility may be confirmed using:
 Doral website
 By calling 1-888-912-3456
 DMAS MediCall voice response system at 1-800-884-9730 or 1-800772-9996.
 If DMAS Medicall voice response system is used, providers
are cautioned to listen to the entire message. Members may
be in a waiver program, such as the Family Planning
Waiver, and may not be eligible for dental benefits.
Interactive Phone System
By dialing 1-888-912-3456 and choosing option 1
providers can access:
 Patient Eligibility
 Limited Claims History
 Fax Back Confirmation of eIVR call
 Spanish Call Handling
Patients eligibility can be verified on the eIVR
along with limited claim history (codes: D0120,
D0150, D0210, D0272, D0274, D0330, D1110,
D1120, D1201, D1203, D1204, D1205, D1351,
D5110, D5120, D5130 and D5140)
Confirmation fax of the eIVR available to
providers who use the system
Option to choose Spanish or English
Enrollee Eligibility – FAMIS MOMS
 FAMIS MOMS receive comprehensive health care
benefits during pregnancy and for two months
following the end of pregnancy-this includes SFC
dental benefits if under twenty one years of age.
Detailed information is available at www.famis.org.
 Providers are encouraged to contact Doral to verify
eligibility prior to rendering services.
Benefits For Enrollees Under Age 21
 SFC provides comprehensive
dental benefits for enrollees under
the age of 21:
Prosthodontics Removable
Prosthodontics Fixed
Oral Surgery
Adjunctive General
 A full explanation of benefits can
be found in the Office Reference
Manual, Exhibit A.
Benefits For Enrollees Age 21 and Older
Coverage for adults, age 21 or older,
is limited to medically necessary oral
surgery and associated diagnostic
Diagnostic services include the oral
examination and selected radiographs
needed to assess the oral health,
diagnose oral pathology, and develop
an adequate treatment plan.
Extractions for adults must be
medically necessary and be
complicating the patient’s general
health as documented by the dentist
or medical provider:
 Severe periodontal infection which
causes acute pain, loss of appetite or
weight due to pain or infection
 Exacerbates a medical
condition/medical management such
as diabetes, heart valve condition
Benefits For Enrollees Age 21 and Older
Services for adults require Prepayment
For all services that require Prepayment
Review, Providers have the option of
requesting prior authorization:
Services requiring prepayment review, require
that proper documentation be submitted with
the claim following treatment in order for the
claim to be considered for reimbursement.
Services requiring prior authorization/predetermination require that documentation
regarding the medical necessity of the
proposed treatment be submitted and
authorization from Doral be obtained before
the services are rendered.
A full explanation of benefits can be found in
the Office Reference Manual, Exhibit B.
Oral surgery procedures not listed in Exhibit
B may be covered under the member’s
medical benefits through the Medicaid,
FAMIS, or FAMIS Plus fee-for-service or
managed care organization (MCO) program.
Office Reference Manual
Policies and procedures
Instructions for claims filing
Benefits and limitations
Instructions regarding services that require prior
Orthodontia criteria
Outreach services
American Academy of Pediatric Dentistry (AAPD) dental
care guidelines
Important phone numbers and addresses
The Office Reference Manual (ORM) is available on
Go to www.doralusa.com. Click on “Providers.”
After logging in, “View Documents”
Download a copy from the DMAS website at
Provider Web Portal (PWP)
Meets accessibility standards put forth
by the ADA (Americans with
Users can use any browser – no longer
limited to “Internet Explorer.”
New improved look for ease of use.
Easy to read menu.
Email form for streamlined
Payment release dates so Providers can
easily track payment dates.
Location information displayed for the
office staff to check accuracy and
update the information via a contact
Claims and authorization entry still
available with accurate reporting and
tracking information.
Enrollee Outreach Initiatives
Broken Appointments
 Broken appointments:
 A major concern for DMAS, VDA, ODDS, and Doral
 Recognized as expensive for dentists
 Lead to dentists unwillingness to participate in the
 In December 2005, Doral implemented the Broken
Appointment Tracking Initiative in order to collect
data to better track, trend, and understand the issue
 Doral uses the information to:
 Educate families regarding the importance of appointments
and compliance with treatment plans
Broken Appointment Initiative
Broken Appointment Tracking Log Outcomes
 Over 10,000 broken appointments from SFC
participating dentists have been received since
Fall 2006.
Enhancements to the Broken Appointment
Tracking Form
Missed appointment - a missed appointment
where the member or member representative did
not call to cancel
Late Notice Cancellation (LNC) - a missed
appointment with a cancellation less than 24
hours prior to the appointment time
Reason codes - 1) forgot about appointment., 2)
conflict with schedule, 3) transportation 4)
illness, 5) other.
Next Steps:
 Broken Appointment Best Practices
 Broken Appointment Focused Survey
 SFC Broken Appointment Pilot Program
SFC Transportation Complaint Form
Smiles For Children Transportation Complaint Form
(* Required fields)
*Today’s Date ___/___/___ Date of Problem ___________ Appointment Time: _______________
*Name of Dental Office: _____________________ *Telephone Number ________________
*Form Completed by _________________*Title ___________ *Fax Number _________________
Dental Office Street Address: _________________________________City ______________________
Patient (Recipient) Name ________________________ Medicaid ID Number: ________________
Name of Transportation Provider if known: _________________________________________
*Nature of Complaint:
 Analyses of data related to
broken appointments indicate
problems with transportation as
one reason for broken
Please check all that apply
Medicaid Recipient NO-SHOW for DENTAL Appointment
If Transportation Issue Known by Dental Office please check all that apply below:
Transportation Provider NO-SHOW (i.e., did not arrive at all)
Transportation Provider was LATE or EARLY
Scheduled Arrival Time _________ Actual Arrival Time _________
Patient did not schedule transportation in time therefore missed appointment
Wrong type of vehicle sent for trip (e.g. needed wheel chair van, needed stretcher, etc …)
Told by LogistiCare at Time_______ Date _______that “No Provider Available” to do the trip
Recipient rode too long on vehicle
Time picked up _______ Arrived _______
Driver did not follow special instructions given for pick up, drop off or return trip
Patient or Family not notified of change in provider, scheduled pick up or return time
Incident/Accident (e.g., vehicle accident, incident on vehicle, etc.) Injuries? Yes___ NO ___
Other Issues with LogistiCare (please explain below)
Ongoing or unresolved issue(s) that have been reported but are still occurring.
Specifics of Incident ____________________________________________________________
First, FAX this form to the QA at your LogistiCare Regional Office. Use the number below:
Region l (Norton)
276-679-1666 ________
Region 2 (Bedford) 540-586-7838 ________
Region 3 (Richmond) 804-236-1586 ________
Region 4 (Norfolk) 866-872-3843 ________
Region 5/6 (C’ville) 434-971-6509 ________
Region 7 (Herndon) 703-707-6513 ________
 Providers are encouraged to
report problems with
transportation to DMAS. The
SFC Transportation Complaint
Form can now be used to report
Second, FAX this form to DMAS at 804-371-6035 in care of Bob Knox, Transportation Mgr or the DMAS
Contract monitor for your region: Bill Zieser (Reg. 1, 3 and 7) or Eileen Jackson (Reg. 2, 4 and
Interpreter Services- Pending Implementation
Title XIX of the Social Security Act requires Medicaid providers to provide non-discriminatory
services to its clients including those with limited English proficiency.
In order to help providers with this requirement, DMAS has implemented a provision for
reimbursement of interpreter services under the SFC program when there is a need and it relates to
the treatment.
In order for the SFC dentist to be reimbursed for interpreter services performed at the dental office,
the provider must submit documentation (invoice) of the services provided by and paid to a
professional interpreter. The following elements must included in the documentation:
Date(s) of Service
Patient name and ID number
Copy of the invoice showing the name, address and telephone number of the professional interpreter service,
the type and length of service, and the amount paid
Mail the SFC Professional Interpreter Service Invoice Form along with the above documentation
Doral Dental
ATTN: Lori Howley
12121 N. Corporate Parkway
Mequon, WI 53092
An interpreter services resource listing will be located on the DMAS website,
http://www.dmas.virginia.gov. A copy of the resource listing will also be available upon request.
How to Locate a Provider
Provider Directory
Provider name
Practice name
Office address(es)
Telephone number(s)
Provider specialty
Panel status
Office hours
Languages spoken
Any other panel limitations
Directory may be downloaded from
the DMAS website at:
from the Doral website at:
Doral Dental USA Website
 Open Microsoft Internet
Explorer and access
 Click on the “Find A
Provider” button to
Find A Provider
 You must provide at
least a zip code to
perform a search.
 Select VA-Smiles
For Children from
the drop down menu.
 Click “Find
Find A Provider Search Results
 Search options
allow you to
narrow a search
Provider Specialty
Languages Spoken
Mileage Radius
Contact Information
Doral Smiles For Children Staff:
DMAS Smiles For Children Staff:
Sandra Brown, MSW:
Dental Program Manager
Direct Line: (804) 786-1567
Fax: (804) 786-5799
Email: sandra.brown@dmas.virginia.gov
Anna Perez:
Provider Relations Representative
Direct Line: (804) 217-8392
Fax: (804) 217-8349
Email: amperez@doralusa.com
Dr. Marjorie Chema, DDS:
Dental Consultant
Direct Line: (804) 786-6635
Fax: (804) 786-5799
Email: marjorie.chema@dmas.virginia.gov
Kristen Gilliam:
Outreach Coordinator
Direct Line: (804) 935-8589
Fax: (804) 217-8350
Email: kfgilliam@doralusa.com
Lisa Bilik:
Dental Contract Monitor
Direct Line: (804) 786-7956
Fax: (804) 786-5799
Email: lisa.bilik@dmas.virginia.gov
Cheryl Harris:
Project Director
Direct Line: (804) 217-8344
Fax: (804) 217-8348
Email: cpharris@doralusa.com
Thank You!

A Presentation for the Old Dominion Dental Society