NHCAA selects Dr. Koumaras as Medical Director of the Year

Transcription

1 2012 Year End For Dentists NHCAA selects Dr. Koumaras as Medical Director of the Year We are pleased to announce that Dr. George Koumaras was selected to receive the Medical Director of the Year Award from the National Healthcare Anti-Fraud Association (NHCAA). Dr. Koumaras was presented with his award at the NHCAA Annual Training Conference on November 14. Dr. Koumaras is being honored for his commitment and dedication to the fight against insurance fraud. New Provider IVR system improves access to information Delta Dental of Virginia has a new Interactive Voice Response (IVR) system! We ve implemented this new system with enhanced voice prompts to improve the delivery of automated information to you and ensure quick access to eligibility and claims information. In order to increase security and accuracy, a new logon process will be required. When you call into our offices, please follow these steps (if you have multiple office In this Issue locations, you will also be asked to verify the location for which Dr. K s Korner you are requesting information): New processing policy for non-standard claims Enter your TIN Enter the last four digits of your state license number OR your individual NPI Enter the subscriber ID # and the patient s DOB You will then be able to access a benefits and eligibility summary (press 1), claims status (press 2), or the last three claims received (press 3). Direct Deposit Eliminate trips to the bank and speed up access to your cash Predetermination of Benefits Valuable service available to you New Individual Benefit Plans Three plans for non-group covered patients Clinical Policy Updates Stay informed of the latest updates Foundation Grants Announcement Inaugural grant recipients are announced Stay Connected in 2013 CE courses back by popular demand

2 New individual benefit plans Delta Dental has discontinued the sale of our Traditional Enhanced Individual product effective 12/1/2012. We have introduced two NEW individual products to take its place Classic and Classic Enhanced. This now brings our individual product portfolio to three products including the Clear plan. You can visit DeltaDentalCoversMe.com for more details on these products. A summary benefit comparison is below: Comparison of Key Benefits Under Delta Dental Individual and Family plans Plan Benefit Enhanced Plan The percent you pay after your deductible (where required) Classic Plan The percent you pay after your deductible (where required) Clear Plan* You pay the fixed dollar amount shown below Cleanings 0% 20% $60 Exams 0% 20% (included in cleaning) Bitewing X-rays 0% 20% (included in cleaning) Topical Fluoride 0% 20% (included in cleaning) Fillings (no waiting period) $75 Crowns $500 Implants $2,250 Root Canals $400 Non-Surgical Extractions $75 *Dollar amounts for the Clear Plan will vary according to region. The amounts shown for the Clear Plan above are applicable only to the Eastern region of Virginia. Plan designs and rates are current as of October Please visit DeltaDentalCoversMe.com or call for the latest plan information and rates. In order to provide our individual subscribers with the most efficient customer service, we are consolidating the administration of our individual products. Current individual subscriber ID cards are valid for any dental visits through December 31, Any claims for services performed through the end of the year should be filed according to the instructions on the back of their current card. Effective January 1, 2013, individual subscribers will be issued new ID cards. For any dental service provided after January 1, 2013, claims should be sent to: Delta Dental, P.O. Box 103, Stevens Point, WI To submit claims electronically after January 1st, please use the Payer ID# WDENC. To view individual subscriber eligibility, benefits and claims after January 1st, you must log onto DeltaDental.com. You will no longer be able to access this information through deltadentalva.com. For any questions regarding services rendered after January 1st, please call

3 Dr K s Dr. George Koumaras Dental Director Delta Dental of Virginia Korner Have a benefits or procedure question you d like to discuss? Dr. K with your questions at DrKsKorner@deltadentalva. com. You ll get a prompt response, and your question and answer may be shared here in our newsletter. New processing policy for non-standard claims An issue has been raised from other Delta Dental member companies regarding inconsistencies in the processing of claims by Delta Dental of Virginia that have been considered non-standard. This relates to benefits for certain types of restorations that are automatically alternated. Current processing policies for all Delta Dental member companies make subscribers responsible for any balance up to the plan allowance, such as the processing policy for composite restorations paid as an amalgam. Standard group restorative dental benefits for posterior teeth only allow for amalgam restorations. Coverage for posterior composites is group specific. As of April 1, 2013, Delta Dental of Virginia will begin processing all claims in the same manner as other Delta Dental member companies. This effort will achieve consistency across the Delta Dental family of companies, decreasing confusion and the number of complaints. Eliminate trips to the bank with direct deposit Delta Dental of Virginia can deposit your claims payments directly into your practice s bank account, streamlining your remittance process and speeding up access to cash. Direct deposit, or Electronic Funds Transfer (EFT), means no more paper checks, no need for deposit slips and, best of all, no more time-consuming trips to the bank. Your claims payments can now be transferred directly from Delta Dental to your checking or savings account. EFT is free and available to all dentists, whether you submit claims by paper or electronically. To eliminate some hassle and get your claims payments faster, sign up for EFT today. Simply visit the Provider section at deltadentalva.com and click on the Forms link to access the Direct Deposit Enrollment Form or call Provider Relations at , ext for more information. Predetermination of benefits Delta Dental of Virginia would like to remind you of a valuable service available to you: Predetermination of benefits review, particularly important for claims exceeding $250. When submitted directly to Delta Dental, it is recommended that diagnostic information, such as X-rays, photographs, narratives, etc. be submitted with any predetermination request to help facilitate timely adjudication. A predetermination of benefits is valid for ninety (90) days. A predetermination of benefits review eliminates confusion for the patient and dentist relative to particular group coverage. Additionally, a benefit predetermination allows you to review the benefit determination prior to performing the procedure to avoid confusion and complaints. Several covered dental procedures are subject to treatment criteria published on our website, deltadentalva.com, under Clinical Policies. The benefit predetermination also allows you the opportunity to appeal procedures either denied or amended. If you have any questions concerning the predetermination, please contact Benefit Services or the dental consultant staff. Also, please be aware when submitting electronic benefit predeterminations through MDE that when the services are rendered and the claim submitted, certain procedures are subject to clinical review, which can change the benefit amount. We recommend informing patients that the benefit and patient responsibility amounts can change for certain treatments. Language is included on the MDE predetermination response indicating the proposed treatment requires clinical review which can alter benefit and patient responsibility amounts. This will help reduce dissatisfaction and complaints.

4 Keep up to date with the latest clinical policy updates The following are a number of important clinical policy updates of which you and your office staff should take note. All updates, as well as the complete Delta Dental of Virginia (DDVA) clinical policies, can be accessed at deltadentalva.com. 1. Lasers Please review the new DDVA Clinical Policy #902, Laser Therapy for Treatment of Periodontal Disease, at deltadentalva.com. This new policy states and clarifies DDVA s position on the adjunctive use of lasers for periodontal treatment. 2. Periodontal Maintenance Please refer to DDVA Clinical Policy #405, Periodontal Maintenance, at deltadentalva.com following revisions to the policy in November The guidelines are currently being expanded to state that, to be eligible for procedure D4910, a patient must have a history of previous definitive therapy (periodontal scaling and root planing) or a surgical procedure for pocket management. Treatment history may be documented by submission of treatment notes or by narrative report. For a patient to remain eligible, periodontal maintenance must be uninterrupted and continuous. A period of 12 months cannot elapse between D4910 appointments. Also, an integral part of a periodontal maintenance appointment is periodontal charting documenting either stability or changes in the periodontal status. When requested as part of documentation for the D4910 procedure, providers should submit periodontal charting completed on the most recent date of service. 3. Guidelines for Sedation/General Anesthesia Please refer to DDVA Clinical Policy #900, General Anesthesia, at deltadentalva.com for guidelines on administering anesthesia to patients. Guidelines noted within clinical policy #900 will be followed effective April 1, According to ADA CDT 2013, anesthesia time (for benefit reporting) begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties. Therefore, benefits for general anesthesia or IV sedation are allowed as noted above for time reporting. It has been determined that 95% of most dentoalveolar procedures, including removal of four complete or partial bone impacted teeth, can typically be accomplished within 60 minutes. When anesthesia is submitted for over 60 minutes, a request will be made for rationale that addresses the additional length of anesthesia time including necessity, the complete anesthesia record documenting start and stop times of drug administration, operative report and all current radiographic images. 4. Osseous Surgery Appropriate documentation of the need for osseous surgery should accompany claims for this procedure. Recent periodontal charting and diagnostic X-rays are required for adjudication of these claims. If X-rays do not demonstrate radiographic evidence of bone loss, a written narrative report with treatment rationale should be submitted as part of documentation. Please refer to DDVA Clinical Policy #404, Osseous Surgery, at deltadentalva.com for complete guidelines. 5. Soft Tissue Grafting Benefits for soft tissue grafting are determined by individual group contract. Coverage under most group contracts allows soft tissue graft procedures at two teeth per quadrant per date of service. Additional grafts over those allowed for two teeth are considered inclusive procedures and will be disallowed. On appeal, with submission of appropriate documentation of need, additional grafts may be considered clinically necessary. However, the subscriber will be responsible for additional fees. It is suggested that providers submit intra-oral photographs, if available, as additional documentation of treatment need. Please refer to DDVA Clinical Policy #402, Mucogingival Surgery and Soft Tissue Grafting, at deltadentalva.com for complete guidelines.

5 Your Team 6. Core Buildups Submission of diagnostic X-rays is required for review of claims for core buildups. A written narrative report is also required if the treatment need is not evident on the radiographs and as described in CDT If the radiograph is not diagnostic for a core buildup, and does not demonstrate significant loss of tooth structure, it is recommended that providers submit intra-oral photographs to help document treatment need. Providers are reminded that replacement of a moderate restoration does not constitute a core buildup. For a restoration to qualify as a core buildup, the tooth must exhibit compromise to the circumferential integrity of the tooth due to significant loss of tooth structure from decay or fracture. Please refer to DDVA Clinical Policy #202, Core Buildup and Pin Retention, at deltadentalva.com for complete guidelines. 7. Radiographs Providers are reminded that submitted radiographs must be current and diagnostic for the proposed procedure. Claims for which radiographs are not current or diagnostic will not be adjudicated. According to CDT 2013, diagnostic imaging should be taken only for clinical reasons as determined by the patient s dentist. Images should be of diagnostic quality and properly identified and dated. Additionally, radiographs must serve some immediate diagnostic need. When considering radiographic examination of patients, providers are reminded to follow the ALARA principle, as recommended by the American Dental Association and U.S Food and Drug Administration. ALARA is an acronym that stands for As Low As Reasonably Achievable. This principle involves making every reasonable effort to maintain radiation exposure as far below the dose limits, consistent with the diagnostic need, as possible. Periodic screening radiographs not based on clinical need or signs and symptoms should not be used simply to confirm health. Providers should be familiar with the most recent ADA/FDA recommendations for dental X-rays.* *Source: The Use of Dental X-rays. Updates and recommendations. J Amer Dent Assoc 2006;137: When you or your staff have questions, the Provider Relations team is ready to help. Please contact us whenever we can be of assistance. Shannon M. Nelson Supervisor, Clinical Professional Services , ext snelson@deltadentalva.com Annette Giles Provider Relations Liaison Western, Southern & Central Virginia , ext apgiles@deltadentalva.com Laurie Cassanese-Rhodes Provider Relations Liaison Hampton Roads, Richmond & Northern Virginia or , ext. 7 lrhodes@deltadentalva.com Ellen Drewery Provider Relations Specialist , ext ellen.drewery@deltadentalva.com Tessa Graybill Credentialing Representative , ext tessa.graybill@deltadentalva.com Delta Dental of Virginia Foundation Grants Announcement The Delta Dental of Virginia Foundation is proud to announce its inaugural grant recipients! In December 2012, the Foundation awarded more than $1.1 million to 36 organizations in Virginia for programs working to improve oral health through education, research or access to care for the underserved. Delta Dental of Virginia is proud to support these oral health initiatives that are working to create sustainable oral health solutions for Virginia s communities, bringing us one step closer to improving the oral health of all Virginians. See the enclosed insert for a list of this year s grant recipients and a map showing their distribution across the state. For more information on the Delta Dental of Virginia Foundation please visit our website at deltadentalva.com/ddvafoundation.aspx.

6 Stay Connected in 2013 Back by popular demand, Delta Dental will be holding two Continuing Education (CE) seminars: one in Roanoke in March and our traditional beach getaway in August. Mark your calendars for: Date: April 26, 2013 Date: Friday, August 16, 2013 City: Roanoke, VA City: Virginia Beach Location: Hotel Roanoke Location: Hilton Virginia Beach Oceanfront Subject: TBD Subject: TBD Speaker: Laura Jamison Speaker: Linda Miles AGD CE Credits: TBD AGD CE Credits: TBD Look for more information on topics and credit hours awarded coming your way soon CE Seminar Highlights DDVA team with Dr. Terry Donovan from the August 2012 CE Seminar in Virginia Beach DDVA Provider Relations team with Linda Miles from March 2012 CE Seminar in Roanoke Delta Dental of Virginia 4818 Starkey Road Roanoke, VA 24018

7 DDVA Foundation Grants Approved for 2012 Map # Organization Purpose 49 Boys & Girls Clubs of Southwest Virginia Smart Smiles At the Dentist program 48 Boys & Girls Clubs of the Blue Ridge Smart Smiles At the Dentist program 5 Boys & Girls Clubs of the Virginia Peninsula Smart Smiles At the Dentist program 18 Bradley Free Clinic Free dental care for uninsured and low-income adults 12 CHIP of Roanoke Valley Fluoride varnish treatments 22 Community Free Clinic of Newport News Subsidize staffing for the clinic s dental program 20 Council of Community Services Roanoke MOM Project support 39 Craig County Rural Health Care Corp. School based dental program 37 Eastern Shore Rural Health System, Inc. Purchase intra-oral digital X-ray & processor 28 Free Clinic of Central Virginia Expansion of dental services 13 Gloucester-Mathews Free Clinic New dental clinic 7 Goochland Free Clinic & Family Services Expand dental services 51 Halifax Regional Health System Subsidize the salary for a dental hygienist 50 Hampton Roads Dental Center Expand access to safety net dental care 44 Health Focus of Southwest VA Scholarships for dental and hygiene students 52 Horizon Health Services, Inc. Subsidize the dentist s salary 32 Lackey Free Clinic Dental equipment for clinic expansion 1 Lloyd F. Moss Free Clinic Dental clinic expansion 16 Northern Neck Free Health Clinic Support for VCU students providing dental services 46 Northern Virginia Dental Clinic Oral health care services to uninsured and underserved adults 56 Park Place Health & Dental Clinic Support for VCU dental students & hygienists working at the dental clinic 36 Piedmont Access to Health (PATH s), Inc. Dental care to uninsured patients 41 Piedmont Regional Dental Clinic Equipment & supplies for mobile dental unit that services schools 23 Piedmont Virginia Dental Health Foundation Cover expenses related to dental & dental hygiene students working in the clinic 19 Rescue Mission of Roanoke Expand dental treatment services 6 Rockbridge Area Free Clinic Subsidize staffing for new clinic 26 Science Museum of Western Virginia bigmouth educational exhibit upgrade 3 Shenandoah Dental Clinic Equipment to expand dental services 15 The Health Wagon Dental equipment 8 VCU School of Dentistry Scholarship funds for dental students 45 Virginia Dental Association Foundation Statewide MOM projects support 21 Virginia Health Care Foundation Dental Opportunities Champion 9 Virginia Health Care Foundation Help establish new dental safety net clinics 34 Virginia Oral Health Coalition Operating support for Coalition activities & sponsorship of the 2013 Oral Health Summit 10 Virginia Tech Carilion School of Medicine Permanently endow the Delta Dental Oral Health Teaching curriculum 59 Western Tidewater Free Clinic, Inc. Subsidize hygienist salary

8 Distribution of 2012 Approved Grants Rockingham Shenandoah 3 Page Frederick Warren Rappahannock Clarke Culpeper Fauquier Loudoun Fairfax Prince William 1 46 Arlington Madison Stafford Alleghany Bath Highland Rockbridge 6 Augusta Nelson Greene Albemarle Fluvanna Orange 7 41 Louisa Goochland Spotsylvania Hanover Caroline King George King William Westmoreland Essex King And Queen Richmond Lancaster 16 Northumberland Accomack 37 Lee 15 Wise Scott Dickenson Buchanan Russell Washington Tazewell Smyth Bland Wythe Grayson Giles Pulaski Carroll 39 Botetourt Craig Roanoke Montgomery Franklin Floyd Patrick Henry Bedford 36 Pittsylvania Amherst Campbell 51 Appomattox Halifax Charlotte Buckingham Prince Edward Cumberland Lunenburg Mecklenburg Amelia Nottoway Powhatan Brunswick Chesterfield Dinwiddie Greensville Henrico Prince George Sussex Charles City Southampton New Kent 52 Surry James City Isle of Wight Middlesex Gloucester Suffolk Newport News 59 York Hampton Portsmouth Norfolk Chesapeake Mathews 22 5 Virginia Beach Northampton The Benefits of Experience