A New Day For Oral Health In Virginia Tooth Talk December 12, 2007 Smiles For Children Program An Overview 2 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 http://www.dss.virginia.gov/ 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) 3 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. 4 Interactive Phone System AVAILABLE 24 HOURS A DAY! 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 5 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. 6 Benefits For Enrollees Under Age 21 SFC provides comprehensive dental benefits for enrollees under the age of 21: – – – – – – – – – – Diagnostic Preventive Restorative Endodontics Periodontics Prosthodontics Removable Prosthodontics Fixed Oral Surgery Orthodontics Adjunctive General A full explanation of benefits can be found in the Office Reference Manual, Exhibit A. 7 Benefits For Enrollees Age 21 and Older Coverage for adults, age 21 or older, is limited to medically necessary oral surgery and associated diagnostic services. 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 8 Benefits For Enrollees Age 21 and Older Services for adults require Prepayment Review: 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. 9 Office Reference Manual Policies and procedures Instructions for claims filing Benefits and limitations Instructions regarding services that require prior authorization 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 line: Go to www.doralusa.com. Click on “Providers.” After logging in, “View Documents” or Download a copy from the DMAS website at http://www.dmas.virginia.gov 10 Provider Web Portal (PWP) Meets accessibility standards put forth by the ADA (Americans with Disabilities). 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 communication. 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 form. Claims and authorization entry still available with accurate reporting and tracking information. 11 Enrollee Outreach Initiatives 12 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 program 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 13 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 Questionnaire Broken Appointment Focused Survey SFC Broken Appointment Pilot Program 14 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 appointments. 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 problems. 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 5/6). 15 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 to: 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. 16 How to Locate a Provider 17 Provider Directory Contents: 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: http://www.dmas.virginia.gov or from the Doral website at: http://www.doralusa.com 18 Doral Dental USA Website Open Microsoft Internet Explorer and access www.doralusa.com. Click on the “Find A Provider” button to continue. 19 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 Providers” 20 Find A Provider Search Results Search options allow you to narrow a search by: Provider Specialty Languages Spoken Mileage Radius Hospital Affiliation 21 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: email@example.com Anna Perez: Provider Relations Representative Direct Line: (804) 217-8392 Fax: (804) 217-8349 Email: firstname.lastname@example.org Dr. Marjorie Chema, DDS: Dental Consultant Direct Line: (804) 786-6635 Fax: (804) 786-5799 Email: email@example.com Kristen Gilliam: Outreach Coordinator Direct Line: (804) 935-8589 Fax: (804) 217-8350 Email: firstname.lastname@example.org Lisa Bilik: Dental Contract Monitor Direct Line: (804) 786-7956 Fax: (804) 786-5799 Email: email@example.com Cheryl Harris: Project Director Direct Line: (804) 217-8344 Fax: (804) 217-8348 Email: firstname.lastname@example.org 22 Thank You!