Network BLUE & FEP Dental Webinar

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1 Network BLUE & FEP Dental Webinar Housekeeping Items: All lines will be muted throughout the webinar If you have any questions during the presentation, you may enter them in the questions box, located to the right on your screen. General questions pertaining to today s topic will be answered at the end of the webinar Also note that during the presentation, your chat box may minimize. If it does, click on the double arrows on the upper right side of your screen The webinar presentation and a recording of the session will be made available within a week of the webinar at: 1

2 Charlie Kennedy Provider Relationship Manager Meredy Stover FEP Service Manager 2

3 Returned and Denied Claims New Codes for 2016 ICD10/Filing a Medical Claim Reducing Paper Submissions Refunds Federal Employee Program 3

4 TOP REASONS FOR RETURNED AND DENIED CLAIMS Handwritten, illegible, and/or writing outside of the appropriate box Tax Identification Number on claims does not match the information on provider s file at BCBSNE Provider information on the claim that does not match the respective BCBSNE provider file Using patient s social security number as the BCBSNE ID number Using the incorrect patient name 4

5 The number of surfaces does not match the code submitted for tooth number Please provide the appropriate tooth surface(s) for the tooth number The ADA code is no longer valid Buccal surface can only be used on posterior teeth Incisal surface can only be used on anterior teeth 5

6 Returned and Denied (cont.) Multiple Periapicals D0220 Periapical first film must be submitted before D0230 Periapical each additional film Bitewings are not considered the 1 st periapical Base, liners, inserts and adhesives should be included in the fee for restoration Unable to determine if extractions were done for orthodontic purposes Provide a breakdown of charges including the date and amount of the initial payment along with the monthly charges for the orthodontic services 6

7 Returned and Denied (cont.) Billing two procedure codes for fillings on same tooth Example: tooth #4 MO code D2150 DO code D2150 Should be billing D2160 for an MOD. If the DDS feels the codes should be separated, they need to send in x-rays supporting the need for the separate codes 7

8 D0251 Extra-oral posterior dental radiographic image D0422 Collection and preparation of genetic sample material for laboratory analysis and report D0423 Genetic test for susceptibility to diseases specimen analysis D0260 Extraoral-each additional radiographic image D0421 Genetic test for susceptibility to oral diseases D1354 Interim caries arresting medicament application D2970 Temporary crown D4283 Autogenous connective tissue graft procedure-each additional contiguous tooth, implant or edentulous tooth position in same graft site D4285 Non-autogenous connective tissue graft procedure-each additional contiguous tooth, implant, or edentulous tooth D5221 Immediate maxillary partial denture-resin base D5222 Immediate mandibular partial denture-resin base D5223 Immediate maxillary partial denture-cast metal framework with resin denture bases D5224 Immediate mandibular partial denture-cast metal framework with resin denture bases D7881 Occlusal orthotic device adjustment D8681 Removable orthodontic retainer adjustment D9223 Deep sedation/general anesthesia each 15 minute increment D9243 Intravenous moderate (conscious) sedation/analgesia-each 15 minute increment D9932 Cleaning and inspection of removable complete denture, maxillary D9933 Cleaning and inspection of removable complete denture, mandibular D9934 Cleaning and inspection of removable partial denture, maxillary D9935 Cleaning and inspection of removable partial denture, mandibular D9943 Occlusal guard adjustment D9220 Deep sedation/general anesthesia-first 30 minutes D9221 Deep sedation/general anesthesia-each additional 15 minutes D9241 Intravenous moderate (conscious) sedation/analgesia-first 30 minutes D9242 Intravenous moderate (conscious) sedation/analgesia-each additional 15 minutes D9931 Cleaning and inspection of a removable appliance 8

9 See Filing for Medical Services in Section 7, Network BLUE Dental Policies and Procedures at Providers, Policies and Procedures File a CMS 1500 claim for accidents, impacted teeth and oral appliances ICD10 codes are SØ1.512A Laceration without foreign body of oral cavity K00.6 Disturbances in Tooth Eruption K01.0 Embedded Tooth K01.1 Impacted Tooth G47.30 Sleep Apnea M26.60 TMJ 9

10 Needed for: Anterior crowns or veneers Crowns placed and the patient has preventative and restorative coverage only Multiple restorations on the same tooth We do NOT need X-rays for posterior teeth except as listed above Periapicals should be placed inside an x-ray envelope with the patient s name, dentist s name and dentist s address Panographs should identify the patient s and the dentist s names as well as the dentist s address 10

11 The Network Blue provider agreement that all dentists sign has the following entry under Section III, Provider Responsibilities: Refunds and Offsets. Provider agrees to refund to BCBSNE or its designee any amount paid in excess of that to which Provider is entitled pursuant to the terms of this Agreement. In the event of excess payment for any reasons BCBSNE may, in addition to any other remedy, recover the same by offsetting the amounts overpaid against current and future amounts due and/or seek refund of the amount in controversy. BCBSNE will not initiate refund processes more than 18 months from the date of any payment under this Agreement; provided, however, that no time limit shall apply to the initiation of refund requests based on a reasonable belief of fraud, abuse, or other intentional misconduct, if required by a state or federal government program, or if another payor is involved in the claim, such as claims involving the coordination of benefits, subrogation or right of reimbursement, and workers compensation coverage. This section shall survive the termination of this Agreement. 11

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13 Agenda FEHB Overview Plans available in Nebraska The Service Benefit Plan (aka FEP ) Standard Option Dental Benefits Basic Option Dental Benefits FEDVIP Overview FEP BlueDental 13

14 FEHB Overview Federal Employee Health Benefits Program Most plans include a small amount of dental coverage in the medical policy FEHB plan is primary to supplemental FEDVIP programs Dependent children covered up to age 26 14

15 Plans Available in Nebraska To view a list of the plans available in Nebraska, you may visit the Office of Personnel Management website at: 15

16 The Service Benefit Plan Also known as FEP Nationwide plan Members can access care anywhere in the United States File claims to your local BCBS plan SBP does not do dental pre-determinations Dental vs medical services Outpatient hospital care 16

17 Standard Option Dental Benefits In- and out-of-network benefits available 2015: cleanings (2 per CY), preventive exams, fluoride/fluoride varnish, limited x-rays, spacers, fillings (amalgam and resin), inlay restorations and extractions are covered as are pulp vitality tests and palliative treatment 2016: does not include spacers, fillings, restorations, extractions and pulp vitality tests FEP pays a flat amount for these services. The member is liable for any amount up to the GRID contracted fee schedule amount for covered services 17

18 Basic Option Dental Benefits In-network benefits only Cleanings (2 per CY), evaluations, limited x-rays (intraoral once every 3 CYs and up to 4 bitewings per CY), fluoride/fluoride varnish for children only (up to 2 per CY) and sealants for first and second molars only (once per tooth up to age 16 only) FEP pays all covered charges except $25 copay for innetwork services 18

19 Service Benefit Plan Brochure Click here to access the Service Benefit Plan brochures. Dental benefits are listed in Section 5(g) Dental Benefits

20 FEDVIP Overview Federal Employee Dental and Vision Insurance Program Available to all federal employees eligible to participate in the FEHB program Comprehensive dental coverage Secondary to FEHB coverage, when present Dependent children covered up to age 22 20

21 FEDVIP Plans Available in Nebraska To view the FEPDVIP plans available to members in Nebraska, click here: 21

22 FEP BlueDental Administered by BCBS of Minnesota 2015 FEP BlueDental brochure: Questions should be directed to FEP BlueDental at Claims Filing: Determine if there is other coverage primary to the FEP BlueDental policy. If one exists, file to the primary carrier first If the Blue Cross and BlueShield Service Benefit Plan is primary, the claim will automatically cross over to FEP BlueDental in most cases If other coverage is primary, the claim must be filed (paper) to FEP BlueDental. Use the FEP BlueDental ID number on the claim form and attach the primary insurer s EOB 22

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24 Network BLUE & FEP Dental Webinar Housekeeping Items: All lines will be muted throughout the webinar If you have any questions during the presentation, you may enter them in the questions box, located to the right on your screen. General questions pertaining to today s topic will be answered at the end of the webinar Also note that during the presentation, your chat box may minimize. If it does, click on the double arrows on the upper right side of your screen The webinar presentation and a recording of the session will be made available within a week of the webinar at: 24

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